MEDICARE: DAX FUITEN PHARM.D

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	183500000X	Pharmacist	051-286415	IL

General Provider Information

NPI Number	:	1255935250
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAX FUITEN PHARM.D

Provider Business Mailing Address
First Line	:	200 N MAIN ST
Second Line	:
City	:	EAST PEORIA
State	:	IL
Zip	:	61611-2549
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 N MAIN ST
Second Line	:
City	:	EAST PEORIA
State	:	IL
Zip	:	61611-2549
Country	:	US
Telephone Number	:	309-694-1496
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/30/2020
Last Update Date	:	11/30/2020

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Directions to “ DAX FUITEN PHARM.D” Practice Location

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