Provider Demographics
NPI:1295347102
Name:HARTZOG, AUSTIN (PHARMD)
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:
Last Name:HARTZOG
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:DR
Other - First Name:AUSTIN
Other - Middle Name:JAMES
Other - Last Name:HARTZOG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2201 SPRINGFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-1541
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5110 VALUE DRIVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46808
Practice Address - Country:US
Practice Address - Phone:260-481-1110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-21
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26028740A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist