Provider Demographics
NPI:1568073401
Name:DALENBERG, JONATHAN (PHARM D)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:DALENBERG
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4311 HIGHWAY 2565
Mailing Address - Street 2:
Mailing Address - City:LOUISA
Mailing Address - State:KY
Mailing Address - Zip Code:41230-1503
Mailing Address - Country:US
Mailing Address - Phone:606-638-3110
Mailing Address - Fax:
Practice Address - Street 1:4311 HIGHWAY 2565
Practice Address - Street 2:
Practice Address - City:LOUISA
Practice Address - State:KY
Practice Address - Zip Code:41230-1503
Practice Address - Country:US
Practice Address - Phone:606-638-3110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY019484183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist