Provider Demographics
NPI:1902202880
Name:WELLNITZ, BRENDA
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:
Last Name:WELLNITZ
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 1:12503 E ZIMMERLY ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67207-6662
Mailing Address - Country:US
Mailing Address - Phone:620-262-1942
Mailing Address - Fax:
Practice Address - Street 1:3211 S SENECA ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67217-3348
Practice Address - Country:US
Practice Address - Phone:316-554-4545
Practice Address - Fax:316-529-9013
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-05
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-14900183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist