=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033492590
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DALE J ISAACS RPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2011
-----------------------------------------------------
Last Update Date | 09/21/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 319 E TIPTON ST
-----------------------------------------------------
City | SEYMOUR
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47274-3513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-522-0620
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 330 MUTTON CREEK DR
-----------------------------------------------------
City | SEYMOUR
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47274-4042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-216-6000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 26018274A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------