Provider Demographics
NPI:1629385398
Name:WENNER, SHANE C (RPH)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:C
Last Name:WENNER
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 1:900 E SANGER ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19124-1034
Mailing Address - Country:US
Mailing Address - Phone:215-743-6349
Mailing Address - Fax:
Practice Address - Street 1:900 E SANGER ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19124-1034
Practice Address - Country:US
Practice Address - Phone:215-743-6349
Practice Address - Fax:215-533-8504
Is Sole Proprietor?:No
Enumeration Date:2010-09-01
Last Update Date:2010-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP041640L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist