Provider Demographics
NPI:1063782944
Name:WACHTEL, PAMELA (PHD)
Entity type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:
Last Name:WACHTEL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 RICHMOND HILL DR
Mailing Address - Street 2:
Mailing Address - City:GENESEO
Mailing Address - State:IL
Mailing Address - Zip Code:61254-1964
Mailing Address - Country:US
Mailing Address - Phone:309-714-8250
Mailing Address - Fax:
Practice Address - Street 1:316 RICHMOND HILL DR
Practice Address - Street 2:
Practice Address - City:GENESEO
Practice Address - State:IL
Practice Address - Zip Code:61254-1964
Practice Address - Country:US
Practice Address - Phone:309-714-8250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-09
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.292749183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist