Provider Demographics
NPI:1386119774
Name:TETRO-WENGER, AMY ELIZABETH (RPH)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:ELIZABETH
Last Name:TETRO-WENGER
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 1:24585 STONE CARVER DR STE 175
Mailing Address - Street 2:
Mailing Address - City:ALDIE
Mailing Address - State:VA
Mailing Address - Zip Code:20105-2798
Mailing Address - Country:US
Mailing Address - Phone:571-367-3914
Mailing Address - Fax:703-542-6788
Practice Address - Street 1:24585 STONE CARVER DR STE 175
Practice Address - Street 2:
Practice Address - City:ALDIE
Practice Address - State:VA
Practice Address - Zip Code:20105-2798
Practice Address - Country:US
Practice Address - Phone:571-367-3914
Practice Address - Fax:703-542-6788
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-11
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP000055693336C0003X
MD184463336C0003X
VA02022152393336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy