Healthcare Provider Details

I. General information

NPI: 1215537154
Provider Name (Legal Business Name): DAVID WINTCZAK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2020
Last Update Date: 10/29/2020
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3205 W STATE ROAD 45
BLOOMINGTON IN
47403-5107
US

IV. Provider business mailing address

4589 JORDAN RD
MARTINSVILLE IN
46151-6545
US

V. Phone/Fax

Practice location:
  • Phone: 812-333-8903
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26027927A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: