Provider Demographics
NPI:1831234228
Name:WITT, ERIC DANIEL (RPH)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:DANIEL
Last Name:WITT
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 1:200 E JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:MEXICO
Mailing Address - State:MO
Mailing Address - Zip Code:65265-2821
Mailing Address - Country:US
Mailing Address - Phone:573-581-7561
Mailing Address - Fax:573-581-4692
Practice Address - Street 1:200 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:MO
Practice Address - Zip Code:65265-2821
Practice Address - Country:US
Practice Address - Phone:573-581-7561
Practice Address - Fax:573-581-4692
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO043943183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist