Provider Demographics
NPI:1457579088
Name:BULTEMEIER, DALE A (RPH)
Entity Type:Individual
Prefix:MR
First Name:DALE
Middle Name:A
Last Name:BULTEMEIER
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 1:13328 PLUMBAGO CT
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46814-8843
Mailing Address - Country:US
Mailing Address - Phone:260-969-2418
Mailing Address - Fax:260-432-0493
Practice Address - Street 1:8101 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4163
Practice Address - Country:US
Practice Address - Phone:260-969-2418
Practice Address - Fax:260-432-0493
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26014654183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist