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General NPI Number Information
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NPI Number | 1205847340
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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 | 08/11/2006
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Last Update Date | 08/28/2007
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Provider Practice Location Address
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Address Line | 609 7TH AVE
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City | DEWITT
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State | IA
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Zip | 52742
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Country | US
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Telephone | 563-659-5041
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Fax |
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Provider Business Mailing Address
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Address Line | 609 7TH AVE
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City | DEWITT
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State | IA
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Zip | 52742
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Country | US
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Telephone | 563-659-5041
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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 | 1212
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License Number State | IA
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Taxonomy #2
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Taxonomy Code | 3336L0003X
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Taxonomy Name | Long Term Care Pharmacy
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License Number |
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License Number State |
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