Provider Demographics
NPI:1538448238
Name:SCHWARTZ, RENESSA
Entity type:Individual
Prefix:
First Name:RENESSA
Middle Name:
Last Name:SCHWARTZ
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 1:515 MERIDIAN ST
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-5420
Mailing Address - Country:US
Mailing Address - Phone:307-399-5923
Mailing Address - Fax:
Practice Address - Street 1:1766 COFFEEN AVE
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-5710
Practice Address - Country:US
Practice Address - Phone:307-674-1936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-11
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3377183500000X
UT7697910-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist