Provider Demographics
NPI:1205847340
Name:DEWITT PHARMACY INC
Entity Type:Organization
Organization Name:DEWITT PHARMACY INC
Other - Org Name:DEWITT PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
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 1:609 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:DEWITT
Mailing Address - State:IA
Mailing Address - Zip Code:52742
Mailing Address - Country:US
Mailing Address - Phone:563-659-5041
Mailing Address - Fax:
Practice Address - Street 1:609 7TH AVE
Practice Address - Street 2:
Practice Address - City:DEWITT
Practice Address - State:IA
Practice Address - Zip Code:52742
Practice Address - Country:US
Practice Address - Phone:563-659-5041
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1212333600000X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0491548Medicaid
1622376OtherOTHER ID NUMBER-COMMERCIAL NUMBER
IA0491548Medicaid