1932224904 NPI number — DEWITTS DRUG STORE L P

Table of content: (NPI 1932224904)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932224904 NPI number — DEWITTS DRUG STORE L P

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEWITTS DRUG STORE L P
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DEWITTS DRUG STORE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1932224904
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/17/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12605 APPALOOSA RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MADERA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93636-8354
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-645-6275
Provider Business Mailing Address Fax Number:
559-645-7007

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
407 ROBERTSON BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHOWCHILLA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93610-2846
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-665-4494
Provider Business Practice Location Address Fax Number:
559-665-3632
Provider Enumeration Date:
03/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DAVIS
Authorized Official First Name:
CARRIE
Authorized Official Middle Name:
Authorized Official Title or Position:
PARTNER/ACCOUNTING
Authorized Official Telephone Number:
559-665-4494

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PHY40751 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0530407 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: PHA407510 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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