Provider Demographics
NPI:1841817723
Name:DOUD, TRENT
Entity type:Individual
Prefix:
First Name:TRENT
Middle Name:
Last Name:DOUD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 691
Mailing Address - Street 2:
Mailing Address - City:WINONA LAKE
Mailing Address - State:IN
Mailing Address - Zip Code:46590-0691
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2400 E CENTER ST
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-3817
Practice Address - Country:US
Practice Address - Phone:574-269-4003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-26
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26027488A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist