Provider Demographics
NPI:1073908448
Name:WITT, STEPHANIE (PHARM D)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:WITT
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 N 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:IA
Mailing Address - Zip Code:51546-1335
Mailing Address - Country:US
Mailing Address - Phone:712-644-2160
Mailing Address - Fax:
Practice Address - Street 1:103 N 4TH AVE
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:IA
Practice Address - Zip Code:51546-1335
Practice Address - Country:US
Practice Address - Phone:712-644-2160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-02
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA21266183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist