Provider Demographics
NPI:1942891171
Name:WYNTERS, MARK ALAN (CPHT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALAN
Last Name:WYNTERS
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:417 GREENBRIAR DR APT 3
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-2232
Mailing Address - Country:US
Mailing Address - Phone:573-462-0810
Mailing Address - Fax:
Practice Address - Street 1:2225 W MARKET ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61705-5014
Practice Address - Country:US
Practice Address - Phone:309-828-8626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-30
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN67034956A183700000X
IL049274552183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician