Provider Demographics
NPI:1710265657
Name:OSTREM, PHILIP M (RPH)
Entity Type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:M
Last Name:OSTREM
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1010 W MADISON ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WASHINGTON
Mailing Address - State:IA
Mailing Address - Zip Code:52353-1624
Mailing Address - Country:US
Mailing Address - Phone:319-331-2552
Mailing Address - Fax:319-339-0399
Practice Address - Street 1:1010 W MADISON ST
Practice Address - Street 2:SUITE 1
Practice Address - City:WASHINGTON
Practice Address - State:IA
Practice Address - Zip Code:52353-1624
Practice Address - Country:US
Practice Address - Phone:319-331-2552
Practice Address - Fax:319-339-0399
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-26
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA17508183500000X
IL051.288713183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist