Provider Demographics
NPI:1134397599
Name:DESTASIO, WENDY C (RPH)
Entity type:Individual
Prefix:MRS
First Name:WENDY
Middle Name:C
Last Name:DESTASIO
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 324
Mailing Address - Street 2:
Mailing Address - City:NASSAU
Mailing Address - State:DE
Mailing Address - Zip Code:19969-0324
Mailing Address - Country:US
Mailing Address - Phone:302-644-7530
Mailing Address - Fax:302-644-7523
Practice Address - Street 1:18578 COASTAL HWY
Practice Address - Street 2:ACME
Practice Address - City:REHOBOTH BEACH
Practice Address - State:DE
Practice Address - Zip Code:19971-6154
Practice Address - Country:US
Practice Address - Phone:302-644-1903
Practice Address - Fax:302-644-1906
Is Sole Proprietor?:No
Enumeration Date:2008-02-19
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEA1-0003346183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEA1-0003346OtherSTATE LICENSE