Provider Demographics
NPI:1770904526
Name:ETHRIDGE, WENDY
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:ETHRIDGE
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 1:14125 PORTRUSH DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-8241
Mailing Address - Country:US
Mailing Address - Phone:407-382-8825
Mailing Address - Fax:
Practice Address - Street 1:4175 S PIPKIN RD
Practice Address - Street 2:SUITE 208
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33811-1699
Practice Address - Country:US
Practice Address - Phone:866-577-1440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-20
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS35010183500000X
FLPU56061835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist