Provider Demographics
NPI:1497093447
Name:DEWITT, COREY
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:DEWITT
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 1:6462 RIVER RUN BLVD
Mailing Address - Street 2:
Mailing Address - City:WEEKI WACHEE
Mailing Address - State:FL
Mailing Address - Zip Code:34607-4007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4096 MARINER BLVD
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34609-2465
Practice Address - Country:US
Practice Address - Phone:352-200-5031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-26
Last Update Date:2013-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS49536183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist