Provider Demographics
NPI:1558728428
Name:BOZARTH, DAVID M (RPH)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:BOZARTH
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 1:1155 E PERSHING RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-4726
Mailing Address - Country:US
Mailing Address - Phone:217-877-2374
Mailing Address - Fax:
Practice Address - Street 1:1155 E PERSHING RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-4726
Practice Address - Country:US
Practice Address - Phone:217-877-2374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-24
Last Update Date:2016-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-032167183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist