Provider Demographics
NPI:1730803255
Name:BAKER, ETHAN (PHARMD)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:BAKER
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:262 PRIVATE DR. 605
Mailing Address - Street 2:
Mailing Address - City:KITTS HILL
Mailing Address - State:OH
Mailing Address - Zip Code:45645
Mailing Address - Country:US
Mailing Address - Phone:740-550-6703
Mailing Address - Fax:
Practice Address - Street 1:1848 OH-141
Practice Address - Street 2:
Practice Address - City:IRONTON
Practice Address - State:OH
Practice Address - Zip Code:45638
Practice Address - Country:US
Practice Address - Phone:740-550-6703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-28
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0013234183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist