Healthcare Provider Details

I. General information

NPI: 1336244821
Provider Name (Legal Business Name): MR. LARRY C DITTMAR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 S LAKE ST
EAST JORDAN MI
49727-9376
US

IV. Provider business mailing address

112 W CAYUGA ST P.0.BOX 352
BELLAIRE MI
49615-8101
US

V. Phone/Fax

Practice location:
  • Phone: 231-536-0901
  • Fax:
Mailing address:
  • Phone: 231-533-8729
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302023411
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: