Provider Demographics
NPI:1174357271
Name:UETRECHT, COREY NICOLE (RPH)
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:NICOLE
Last Name:UETRECHT
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 1:9217 BOBCAT TRL
Mailing Address - Street 2:
Mailing Address - City:LEO
Mailing Address - State:IN
Mailing Address - Zip Code:46765-9380
Mailing Address - Country:US
Mailing Address - Phone:260-414-4043
Mailing Address - Fax:
Practice Address - Street 1:11109 PARKVIEW PLAZA DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1701
Practice Address - Country:US
Practice Address - Phone:260-266-9194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-29
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26030993A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist