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General NPI Number Information
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NPI Number | 1013928522
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Entity Type | Organization
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Legal Business Name | DEWITT PHARMACY INC
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Dates
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Enumeration Date | 08/10/2006
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Last Update Date | 08/28/2007
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Provider Practice Location Address
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Address Line | 1021 11TH ST
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City | DE WITT
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State | IA
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Zip | 52742-1209
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Country | US
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Telephone | 563-659-8910
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Fax | 563-659-8411
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Provider Business Mailing Address
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Address Line | 629 6TH AVE
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City | DE WITT
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State | IA
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Zip | 52742-1635
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Country | US
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Telephone | 563-659-5042
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DENNIS BOUSSELOT
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Credential | RPH
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Telephone | 563-659-5042
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number | 1228
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License Number State | IA
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number |
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License Number State |
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