Provider Demographics
NPI:1477195758
Name:WERSHOVEN, CARLY RAE (RPH)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:RAE
Last Name:WERSHOVEN
Suffix:
Gender:F
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:PO BOX 101
Mailing Address - Street 2:
Mailing Address - City:WHITINGHAM
Mailing Address - State:VT
Mailing Address - Zip Code:05361-0101
Mailing Address - Country:US
Mailing Address - Phone:802-368-7277
Mailing Address - Fax:
Practice Address - Street 1:107 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:VT
Practice Address - Zip Code:05363-4000
Practice Address - Country:US
Practice Address - Phone:802-464-7575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-08
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT033.0134331183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist