Provider Demographics
NPI:1174630735
Name:DEWITT PHARMACY INC
Entity Type:Organization
Organization Name:DEWITT PHARMACY INC
Other - Org Name:SCOTT THRIFTY WHITE DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUSSELOT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:563-659-5042
Mailing Address - Street 1:629 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:DE WITT
Mailing Address - State:IA
Mailing Address - Zip Code:52742-1635
Mailing Address - Country:US
Mailing Address - Phone:563-659-5042
Mailing Address - Fax:563-659-5044
Practice Address - Street 1:629 6TH AVE
Practice Address - Street 2:
Practice Address - City:DE WITT
Practice Address - State:IA
Practice Address - Zip Code:52742-1635
Practice Address - Country:US
Practice Address - Phone:563-659-5042
Practice Address - Fax:563-659-5044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IA2803336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0143404Medicaid
1610167OtherNCPDP PROVIDER IDENTIFICATION NUMBER
4108330001Medicare NSC