Healthcare Provider Details

I. General information

NPI: 1174630461
Provider Name (Legal Business Name): SCHWIETERMAN'S DRUG STORE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 05/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1302 DEFIANCE ST
WAPAKONETA OH
45895-1081
US

IV. Provider business mailing address

1302 DEFIANCE ST
WAPAKONETA OH
45895-1081
US

V. Phone/Fax

Practice location:
  • Phone: 419-738-5959
  • Fax: 419-738-3019
Mailing address:
  • Phone: 419-738-5959
  • Fax: 419-738-3019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number02-385050
License Number StateOH

VIII. Authorized Official

Name: MR. MARK STEPHEN DOMINIK
Title or Position: PRESIDENT
Credential: R.PH.
Phone: 419-629-2336