Provider Demographics
NPI:1932224904
Name:DEWITTS DRUG STORE L P
Entity Type:Organization
Organization Name:DEWITTS DRUG STORE L P
Other - Org Name:DEWITTS DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER/ACCOUNTING
Authorized Official - Prefix:
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-665-4494
Mailing Address - Street 1:12605 APPALOOSA RD
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93636-8354
Mailing Address - Country:US
Mailing Address - Phone:559-645-6275
Mailing Address - Fax:559-645-7007
Practice Address - Street 1:407 ROBERTSON BLVD
Practice Address - Street 2:
Practice Address - City:CHOWCHILLA
Practice Address - State:CA
Practice Address - Zip Code:93610-2846
Practice Address - Country:US
Practice Address - Phone:559-665-4494
Practice Address - Fax:559-665-3632
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY407513336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0530407OtherNCPDP PROVIDER IDENTIFICATION NUMBER
CAPHA407510Medicaid
0873130001Medicare NSC