Provider Demographics
NPI:1134520448
Name:BRIAN EDWARD WACHT
Entity type:Organization
Organization Name:BRIAN EDWARD WACHT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:WACHT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:330-550-2061
Mailing Address - Street 1:111 WOODLAND RUN
Mailing Address - Street 2:
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-8705
Mailing Address - Country:US
Mailing Address - Phone:330-550-2061
Mailing Address - Fax:
Practice Address - Street 1:4475 MAHONING AVE
Practice Address - Street 2:
Practice Address - City:AUSTINTOWN
Practice Address - State:OH
Practice Address - Zip Code:44515-1602
Practice Address - Country:US
Practice Address - Phone:330-793-2429
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-07
Last Update Date:2014-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03122584183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty