Provider Demographics
NPI:1669968764
Name:PUTNAM, DALTON R (PHARMD)
Entity type:Individual
Prefix:DR
First Name:DALTON
Middle Name:R
Last Name:PUTNAM
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 W KEARNEY ST STE 116
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65803-2055
Mailing Address - Country:US
Mailing Address - Phone:417-865-1547
Mailing Address - Fax:
Practice Address - Street 1:2650 W KEARNEY ST STE 116
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65803-2055
Practice Address - Country:US
Practice Address - Phone:417-865-7547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-02
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018020490183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist