MEDICARE: MRS. MARY JO WITHERED REGISTERED PHARMACIS

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	IN26013681A	IN

General Provider Information

NPI Number	:	1679868285
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY JO WITHERED REGISTERED PHARMACIS

Provider Business Mailing Address
First Line	:	3630 STATE ROAD 26 E
Second Line	:	T-1762
City	:	LAFAYETTE
State	:	IN
Zip	:	47905-4807
Country	:	US
Telephone Number	:	765-447-4411
Fax Number	:

Provider Business Practice Location Address
First Line	:	3630 STATE ROAD 26 E
Second Line	:	T-1762
City	:	LAFAYETTE
State	:	IN
Zip	:	47905-4807
Country	:	US
Telephone Number	:	765-447-4411
Fax Number	:

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

Provider Enumeration Date	:	06/10/2011
Last Update Date	:	06/10/2011

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