Provider Demographics
NPI:1326392127
Name:KITTLESON, DOUGLAS D (RPH)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:D
Last Name:KITTLESON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-1500
Mailing Address - Country:US
Mailing Address - Phone:608-754-0286
Mailing Address - Fax:608-754-0027
Practice Address - Street 1:1010 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-1500
Practice Address - Country:US
Practice Address - Phone:608-754-0286
Practice Address - Fax:608-754-0027
Is Sole Proprietor?:No
Enumeration Date:2012-10-31
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12592-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist