Provider Demographics
NPI:1427185644
Name:DOXTATER, TODD (RPH)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:DOXTATER
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 1:505 KOKKE LN
Mailing Address - Street 2:
Mailing Address - City:KIMBERLY
Mailing Address - State:WI
Mailing Address - Zip Code:54136-2354
Mailing Address - Country:US
Mailing Address - Phone:920-687-0548
Mailing Address - Fax:
Practice Address - Street 1:800 E MAES AVE
Practice Address - Street 2:
Practice Address - City:KIMBERLY
Practice Address - State:WI
Practice Address - Zip Code:54136-1527
Practice Address - Country:US
Practice Address - Phone:920-788-9154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12156040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist