Provider Demographics
NPI:1790388890
Name:AUGUSTINE, ZANE JOSEPH
Entity Type:Individual
Prefix:
First Name:ZANE
Middle Name:JOSEPH
Last Name:AUGUSTINE
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 1:3719 KETTERING CT APT 105
Mailing Address - Street 2:
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-6651
Mailing Address - Country:US
Mailing Address - Phone:724-355-3092
Mailing Address - Fax:
Practice Address - Street 1:200 E DAYTON YELLOW SPRINGS RD
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-3906
Practice Address - Country:US
Practice Address - Phone:937-878-3991
Practice Address - Fax:937-878-3868
Is Sole Proprietor?:No
Enumeration Date:2020-11-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3438926183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist