Provider Demographics
NPI:1568577583
Name:WYNN, TOM M (RPH)
Entity Type:Individual
Prefix:MR
First Name:TOM
Middle Name:M
Last Name:WYNN
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 1:814 PINEHURST DR
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-9645
Mailing Address - Country:US
Mailing Address - Phone:859-426-1539
Mailing Address - Fax:
Practice Address - Street 1:7717 BEECHMONT AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45255-4203
Practice Address - Country:US
Practice Address - Phone:513-231-1943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03323994183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist