Provider Demographics
NPI:1740750488
Name:WITT, PRESTON JAMES (PHARMACIST)
Entity type:Individual
Prefix:
First Name:PRESTON
Middle Name:JAMES
Last Name:WITT
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13687 SUMMIT DR
Mailing Address - Street 2:
Mailing Address - City:CLIVE
Mailing Address - State:IA
Mailing Address - Zip Code:50325-8661
Mailing Address - Country:US
Mailing Address - Phone:515-225-3046
Mailing Address - Fax:
Practice Address - Street 1:13687 SUMMIT DRIVE
Practice Address - Street 2:
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-5032
Practice Address - Country:US
Practice Address - Phone:515-225-3046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-26
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA16824333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy