MEDICARE: SCHWIETERMAN'S DRUG STORE INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	02-385050	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174630461
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SCHWIETERMAN'S DRUG STORE INC

Provider Business Mailing Address
First Line	:	1302 DEFIANCE ST
Second Line	:
City	:	WAPAKONETA
State	:	OH
Zip	:	45895-1081
Country	:	US
Telephone Number	:	419-738-5959
Fax Number	:	419-738-3019

Provider Business Practice Location Address
First Line	:	1302 DEFIANCE ST
Second Line	:
City	:	WAPAKONETA
State	:	OH
Zip	:	45895-1081
Country	:	US
Telephone Number	:	419-738-5959
Fax Number	:	419-738-3019

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. MARK STEPHEN DOMINIK
Credential	:	R.PH.
Telephone Number	:	419-629-2336

Provider Enumeration Date	:	08/24/2006
Last Update Date	:	05/23/2011

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