Provider Demographics
NPI:1891054516
Name:SIMONTON, WENDY
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:SIMONTON
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 1:3445 FREEDOM DRIVE
Mailing Address - Street 2:T-670
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704
Mailing Address - Country:US
Mailing Address - Phone:217-546-3270
Mailing Address - Fax:
Practice Address - Street 1:3445 FREEDOM DR
Practice Address - Street 2:T-670
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-6517
Practice Address - Country:US
Practice Address - Phone:217-546-3270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-15
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051035402183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist