Provider Demographics
NPI:1164704961
Name:WITHAM, DANIEL RAYMOND (PHARMD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:RAYMOND
Last Name:WITHAM
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7920 SHAVER ROAD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-5121
Mailing Address - Country:US
Mailing Address - Phone:269-324-9988
Mailing Address - Fax:
Practice Address - Street 1:7920 SHAVER RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-5121
Practice Address - Country:US
Practice Address - Phone:269-324-9988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-16
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302026301183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist