Provider Demographics
NPI:1801921267
Name:MITTERMANN, JOHN ROSS (RPH)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:ROSS
Last Name:MITTERMANN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:211 MORGAN ST
Mailing Address - Street 2:
Mailing Address - City:KEOKUK
Mailing Address - State:IA
Mailing Address - Zip Code:52632-5942
Mailing Address - Country:US
Mailing Address - Phone:319-572-8003
Mailing Address - Fax:
Practice Address - Street 1:1400 HARRISON ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-6706
Practice Address - Country:US
Practice Address - Phone:217-222-2930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-028824183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist