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MR. DAVID EDWARD DETIENNE RPH

>> Pharmacist >> Pharmacy Service Providers

Registrant NPI Number: 1174663363

Individual Registrant:
MR. DAVID EDWARD DETIENNE RPH
Gender: M
Not Sole Proprietor

Location and contact information for practice:
4404 STATE ROAD 70  WEBSTER, WI 54893-9251 US
Tel: 715-349-8554  Fax: --

Contact information for business:
329 W WISCONSIN AVE  GRANTSBURG, WI 54840-7818 US
Tel: 715-463-3743  Fax: --

Registration Information:
NPI: 1174663363
Entity Type: Individual

Specialty information:

PrimaryCodeCategory/DescriptionStateLicense Number
Y183500000XPharmacy Service Providers
Pharmacist
WI11821-040

Legacy codes, insurance codes and state license numbers:

IssuerNumberStateType
WISCONS PHARMACIST LICENS11821-040WI01




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