Provider Demographics
NPI:1104815257
Name:HERZOG, WILLIAM WAYNE (RPH)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:WAYNE
Last Name:HERZOG
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 1:5502 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014
Mailing Address - Country:US
Mailing Address - Phone:513-874-5868
Mailing Address - Fax:513-874-0345
Practice Address - Street 1:5502 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:FAUIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014
Practice Address - Country:US
Practice Address - Phone:513-874-5868
Practice Address - Fax:513-874-0345
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-3-11683183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist