Basic Information
| Provider Information | |||||||||
| NPI: | 1871570036 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WETRICH | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | ALAN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | RPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21 BIRCHWOOD DR | ||||||||
| Address2: | |||||||||
| City: | OTTUMWA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 525011416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6416846788 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 507 N MADISON ST | ||||||||
| Address2: | |||||||||
| City: | BLOOMFIELD | ||||||||
| State: | IA | ||||||||
| PostalCode: | 525371271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6416642145 | ||||||||
| FaxNumber: | 6416642421 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 16034 | WA | N | Pharmacy Service Providers | Pharmacist | 183500000X | 17405 | IA | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.