Provider Demographics
NPI:1316321292
Name:WITTERS, STEPHANIE ELIZABETH (PHARM D)
Entity type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:ELIZABETH
Last Name:WITTERS
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:DIANNE
Other - Last Name:WEIDERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1310 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402
Mailing Address - Country:US
Mailing Address - Phone:419-352-1645
Mailing Address - Fax:
Practice Address - Street 1:1310 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402
Practice Address - Country:US
Practice Address - Phone:605-692-8881
Practice Address - Fax:605-692-5833
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-10
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD6209183500000X
MN122118183500000X
OH03337652183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD8502790Medicaid
OH1313627855OtherNPI