Provider Demographics
NPI:1023738077
Name:PENNYWITT, ETHAN (PHARMD)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:PENNYWITT
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 SILVER PINE CIR APT 30
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-9804
Mailing Address - Country:US
Mailing Address - Phone:419-973-5720
Mailing Address - Fax:
Practice Address - Street 1:419 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-1859
Practice Address - Country:US
Practice Address - Phone:989-732-5220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-30
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302414620183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist