Provider Demographics
NPI:1093940652
Name:WITHERELL, ALAN DALE
Entity Type:Individual
Prefix:MR
First Name:ALAN
Middle Name:DALE
Last Name:WITHERELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10503 FISICHELLA LN
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93314-8147
Mailing Address - Country:US
Mailing Address - Phone:661-873-5190
Mailing Address - Fax:
Practice Address - Street 1:9001 STOCKDALE HWY STE 28HC
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93311-1022
Practice Address - Country:US
Practice Address - Phone:661-654-3304
Practice Address - Fax:661-654-2573
Is Sole Proprietor?:No
Enumeration Date:2009-05-26
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58428183500000X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1835P0018XOtherFAMILY PACT