Provider Demographics
NPI:1366742876
Name:WETTERGREEN, DAVID (RPH)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:WETTERGREEN
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 1:3840 LA SIERRA AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-3528
Mailing Address - Country:US
Mailing Address - Phone:951-359-4651
Mailing Address - Fax:951-359-1398
Practice Address - Street 1:3840 LA SIERRA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-3528
Practice Address - Country:US
Practice Address - Phone:951-359-4651
Practice Address - Fax:951-359-1398
Is Sole Proprietor?:No
Enumeration Date:2010-10-31
Last Update Date:2010-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH40284183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist