Provider Demographics
NPI:1831688100
Name:METTLER, MARYLOU CECELIA (RPH)
Entity type:Individual
Prefix:MRS
First Name:MARYLOU
Middle Name:CECELIA
Last Name:METTLER
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 1:1900 CAREW ST STE 4
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-4765
Mailing Address - Country:US
Mailing Address - Phone:260-373-9775
Mailing Address - Fax:260-373-9789
Practice Address - Street 1:1900 CAREW ST STE 4
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4765
Practice Address - Country:US
Practice Address - Phone:260-373-9775
Practice Address - Fax:260-373-9789
Is Sole Proprietor?:No
Enumeration Date:2018-05-02
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS26015690A183500000X
IN2601569A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist