Provider Demographics
NPI:1598161515
Name:DALTON, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:DALTON
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 1:1620 RIVERS BND APT 301
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3066
Mailing Address - Country:US
Mailing Address - Phone:262-227-0525
Mailing Address - Fax:
Practice Address - Street 1:6442 N 76TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53223-6102
Practice Address - Country:US
Practice Address - Phone:414-353-5620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-18
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17649-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist