Provider Demographics
NPI:1467751206
Name:HANEBERG, CONRAD FRANCIS (RPH)
Entity Type:Individual
Prefix:MR
First Name:CONRAD
Middle Name:FRANCIS
Last Name:HANEBERG
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ORRVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44667-1910
Mailing Address - Country:US
Mailing Address - Phone:330-683-8711
Mailing Address - Fax:330-683-9306
Practice Address - Street 1:222 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ORRVILLE
Practice Address - State:OH
Practice Address - Zip Code:44667-1910
Practice Address - Country:US
Practice Address - Phone:330-683-8711
Practice Address - Fax:330-683-9306
Is Sole Proprietor?:No
Enumeration Date:2011-03-18
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03109451183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist