1063493047 NPI number — MR. KEITH A WITT R.PH.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063493047 NPI number — MR. KEITH A WITT R.PH.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WITT
Provider First Name:
KEITH
Provider Middle Name:
A
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
R.PH.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1063493047
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/19/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3284 MAIN ST
Provider Second Line Business Mailing Address:
P.O. BOX 255
Provider Business Mailing Address City Name:
EAST TROY
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53120-1152
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-642-3510
Provider Business Mailing Address Fax Number:
262-642-3512

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3284 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST TROY
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53120-1152
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-642-3510
Provider Business Practice Location Address Fax Number:
262-642-3512
Provider Enumeration Date:
11/08/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  051-033918 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 183500000X , with the licence number: 11834-040 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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