Provider Demographics
NPI:1629678750
Name:BRENNEMAN, TED WILLIAM (RPH)
Entity Type:Individual
Prefix:
First Name:TED
Middle Name:WILLIAM
Last Name:BRENNEMAN
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 1:8122 HOAGLIN CENTER RD
Mailing Address - Street 2:
Mailing Address - City:VAN WERT
Mailing Address - State:OH
Mailing Address - Zip Code:45891-9672
Mailing Address - Country:US
Mailing Address - Phone:419-302-2804
Mailing Address - Fax:
Practice Address - Street 1:301 TOWN CENTER BLVD
Practice Address - Street 2:
Practice Address - City:VAN WERT
Practice Address - State:OH
Practice Address - Zip Code:45891-9087
Practice Address - Country:US
Practice Address - Phone:419-238-5928
Practice Address - Fax:419-238-6057
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03122433183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist