Provider Demographics
NPI:1861805236
Name:BAUM, TIFFANY
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:BAUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15985 OTSEGO PIKE
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:OH
Mailing Address - Zip Code:43569-9767
Mailing Address - Country:US
Mailing Address - Phone:419-669-4460
Mailing Address - Fax:
Practice Address - Street 1:608 CLINTON ST
Practice Address - Street 2:
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-2637
Practice Address - Country:US
Practice Address - Phone:419-782-0155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-03
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03232940183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist