MEDICARE: MADYSON DEWITT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	21373-40	WI

General Provider Information

NPI Number	:	1164158291
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MADYSON DEWITT

Provider Business Mailing Address
First Line	:	1305 N CASALOMA DR
Second Line	:
City	:	GRAND CHUTE
State	:	WI
Zip	:	54913-8848
Country	:	US
Telephone Number	:	920-730-8218
Fax Number	:

Provider Business Practice Location Address
First Line	:	1305 N CASALOMA DR
Second Line	:
City	:	GRAND CHUTE
State	:	WI
Zip	:	54913-8848
Country	:	US
Telephone Number	:	920-730-8218
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/29/2022
Last Update Date	:	07/29/2022

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Directions to “ MADYSON DEWITT ” Practice Location

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