Provider Demographics
NPI:1689276271
Name:FORTWENDEL, COREY (PHARMD)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:FORTWENDEL
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:ROCKPORT
Mailing Address - State:IN
Mailing Address - Zip Code:47635-1123
Mailing Address - Country:US
Mailing Address - Phone:812-649-2227
Mailing Address - Fax:
Practice Address - Street 1:815 SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:IN
Practice Address - Zip Code:47635-1123
Practice Address - Country:US
Practice Address - Phone:812-649-2227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26028516A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist