Provider Demographics
NPI:1033937297
Name:HERZOG, AUSTIN MITCHELL
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:MITCHELL
Last Name:HERZOG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 STADIUM MALL DR
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47907-2091
Mailing Address - Country:US
Mailing Address - Phone:765-494-1374
Mailing Address - Fax:765-496-6094
Practice Address - Street 1:575 STADIUM MALL DR
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47907-2091
Practice Address - Country:US
Practice Address - Phone:765-494-1374
Practice Address - Fax:765-496-6094
Is Sole Proprietor?:No
Enumeration Date:2024-09-27
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26031043A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist