Provider Demographics
NPI:1952969651
Name:DESTITO, JOHN EDWARD (PHARMD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:EDWARD
Last Name:DESTITO
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 1:246 KOKANEE DR
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-5502
Mailing Address - Country:US
Mailing Address - Phone:509-301-9651
Mailing Address - Fax:
Practice Address - Street 1:105 SW 2ND AVE
Practice Address - Street 2:
Practice Address - City:MILTON FREEWATER
Practice Address - State:OR
Practice Address - Zip Code:97862-1373
Practice Address - Country:US
Practice Address - Phone:541-938-8778
Practice Address - Fax:541-938-6072
Is Sole Proprietor?:No
Enumeration Date:2019-05-29
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0017219183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist