Provider Demographics
NPI:1174047450
Name:ETTMAN, MILES KENNETH (RPH)
Entity type:Individual
Prefix:MR
First Name:MILES
Middle Name:KENNETH
Last Name:ETTMAN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 N HERMITAGE AVE
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08618-5531
Mailing Address - Country:US
Mailing Address - Phone:609-394-0600
Mailing Address - Fax:609-394-5505
Practice Address - Street 1:215 N HERMITAGE AVE
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08618-5531
Practice Address - Country:US
Practice Address - Phone:609-394-0600
Practice Address - Fax:609-394-5505
Is Sole Proprietor?:No
Enumeration Date:2017-07-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI01439600183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist