Provider Demographics
NPI:1497090252
Name:WYATT, DONALD III (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:
Last Name:WYATT
Suffix:III
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 1:3405 MCHENRY AVE
Mailing Address - Street 2:T-0273
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-1445
Mailing Address - Country:US
Mailing Address - Phone:209-523-6210
Mailing Address - Fax:
Practice Address - Street 1:3405 MCHENRY AVE
Practice Address - Street 2:T-0273
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-1445
Practice Address - Country:US
Practice Address - Phone:209-523-6210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-05
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA68413183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist