Provider Demographics
NPI:1528187630
Name:WITHERWAX, DENNIS CLAYTON (RPH)
Entity Type:Individual
Prefix:MR
First Name:DENNIS
Middle Name:CLAYTON
Last Name:WITHERWAX
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 1:1120 W LA PALMA AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-2801
Mailing Address - Country:US
Mailing Address - Phone:714-776-2800
Mailing Address - Fax:714-776-2118
Practice Address - Street 1:1120 W LA PALMA AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-2801
Practice Address - Country:US
Practice Address - Phone:714-776-2800
Practice Address - Fax:714-776-2118
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25141183500000X
NV3996183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA25141OtherPHARMACY LICENSE
NV03996OtherPHARMACY LICENSE