Provider Demographics
NPI:1700401783
Name:PURTER, DEWAYNE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:DEWAYNE
Middle Name:
Last Name:PURTER
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 1:4530 KENNY RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-3509
Mailing Address - Country:US
Mailing Address - Phone:614-326-0689
Mailing Address - Fax:614-326-0718
Practice Address - Street 1:4530 KENNY RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220-3509
Practice Address - Country:US
Practice Address - Phone:614-326-0689
Practice Address - Fax:614-326-0718
Is Sole Proprietor?:No
Enumeration Date:2020-06-15
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03334797183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2621309Medicaid