Provider Demographics
NPI:1770250417
Name:FETHEROLF, CHRIS T
Entity Type:Individual
Prefix:MRS
First Name:CHRIS
Middle Name:T
Last Name:FETHEROLF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:OH
Mailing Address - Zip Code:43140-9326
Mailing Address - Country:US
Mailing Address - Phone:740-852-2726
Mailing Address - Fax:
Practice Address - Street 1:375 LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:OH
Practice Address - Zip Code:43140-9326
Practice Address - Country:US
Practice Address - Phone:740-852-2726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-29
Last Update Date:2021-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2303-7848183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician