Provider Demographics
NPI:1205104528
Name:WITTWER, JEREMY RICHARD (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:RICHARD
Last Name:WITTWER
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6143 U S HIGHWAY 98 STE 80
Mailing Address - Street 2:TARGET STORE 2055
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-4405
Mailing Address - Country:US
Mailing Address - Phone:601-296-9245
Mailing Address - Fax:601-329-2477
Practice Address - Street 1:6143 U S HIGHWAY 98 STE 80
Practice Address - Street 2:TARGET STORE 2055
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-4405
Practice Address - Country:US
Practice Address - Phone:601-296-9245
Practice Address - Fax:601-329-2477
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-01
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE11881183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist