Provider Demographics
NPI:1164158291
Name:DEWITT, MADYSON
Entity Type:Individual
Prefix:
First Name:MADYSON
Middle Name:
Last Name:DEWITT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 N CASALOMA DR
Mailing Address - Street 2:
Mailing Address - City:GRAND CHUTE
Mailing Address - State:WI
Mailing Address - Zip Code:54913-8848
Mailing Address - Country:US
Mailing Address - Phone:920-730-8218
Mailing Address - Fax:
Practice Address - Street 1:1305 N CASALOMA DR
Practice Address - Street 2:
Practice Address - City:GRAND CHUTE
Practice Address - State:WI
Practice Address - Zip Code:54913-8848
Practice Address - Country:US
Practice Address - Phone:920-730-8218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-29
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21373-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist