Provider Demographics
NPI:1871765024
Name:WITTMAN, KATHY ANN (RPH)
Entity type:Individual
Prefix:MS
First Name:KATHY
Middle Name:ANN
Last Name:WITTMAN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6272 FURNACE RD
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:NY
Mailing Address - Zip Code:14519-8974
Mailing Address - Country:US
Mailing Address - Phone:315-524-9096
Mailing Address - Fax:315-524-9738
Practice Address - Street 1:6272 FURNACE RD
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:NY
Practice Address - Zip Code:14519-8974
Practice Address - Country:US
Practice Address - Phone:315-524-9096
Practice Address - Fax:315-524-9738
Is Sole Proprietor?:No
Enumeration Date:2008-03-27
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032324183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01772921Medicaid