Provider Demographics
NPI:1205306370
Name:FONDRIEST, MARK (RPH, DPLA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:FONDRIEST
Suffix:
Gender:M
Credentials:RPH, DPLA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3821 PINWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:NORTON
Mailing Address - State:OH
Mailing Address - Zip Code:44203-9505
Mailing Address - Country:US
Mailing Address - Phone:614-314-2356
Mailing Address - Fax:
Practice Address - Street 1:44 BLAINE AVE
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:OH
Practice Address - Zip Code:44146-2709
Practice Address - Country:US
Practice Address - Phone:440-735-3595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-30
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03223754183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist