Provider Demographics
NPI:1215537154
Name:WINTCZAK, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:WINTCZAK
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 1:4589 JORDAN RD
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46151-6545
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3205 W STATE ROAD 45
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-5107
Practice Address - Country:US
Practice Address - Phone:812-333-8903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26027927A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist