Provider Demographics
NPI:1790008639
Name:KIENHOLZ, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:KIENHOLZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2873 W 26TH ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-3047
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2873 W 26TH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16506-3047
Practice Address - Country:US
Practice Address - Phone:814-835-2353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-06
Last Update Date:2010-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP030103L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARP030103LOtherPA LICENSE