Provider Demographics
NPI:1780806430
Name:ENSTROM, RENEE
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:ENSTROM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 ROCKAWAY DR
Mailing Address - Street 2:
Mailing Address - City:ROAMING SHORES
Mailing Address - State:OH
Mailing Address - Zip Code:44085-9706
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5 E ASHTABULA ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:OH
Practice Address - Zip Code:44047-1162
Practice Address - Country:US
Practice Address - Phone:440-576-3921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-1-27165183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist