Provider Demographics
NPI:1316595721
Name:ALTSTADT, DYLAN SUMNER (PHARMD)
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:SUMNER
Last Name:ALTSTADT
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 1:9243 E BASELINE RD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-8308
Mailing Address - Country:US
Mailing Address - Phone:480-986-4660
Mailing Address - Fax:
Practice Address - Street 1:9243 E BASELINE RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-8308
Practice Address - Country:US
Practice Address - Phone:480-986-4660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-28
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS024188183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist