Provider Demographics
NPI:1336244821
Name:DITTMAR, LARRY C
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:C
Last Name:DITTMAR
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 1:112 W CAYUGA ST
Mailing Address - Street 2:P.0.BOX 352
Mailing Address - City:BELLAIRE
Mailing Address - State:MI
Mailing Address - Zip Code:49615-8101
Mailing Address - Country:US
Mailing Address - Phone:231-533-8729
Mailing Address - Fax:
Practice Address - Street 1:250 S LAKE ST
Practice Address - Street 2:
Practice Address - City:EAST JORDAN
Practice Address - State:MI
Practice Address - Zip Code:49727-9376
Practice Address - Country:US
Practice Address - Phone:231-536-0901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302023411183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist