Individual
MR. DAVID EDWARD DETIENNE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
RPH
Contact information
Practice address
4404 STATE ROAD 70, WEBSTER, WI 54893-9251
(715) 349-8554
Mailing address
329 W WISCONSIN AVE, GRANTSBURG, WI 54840-7818
(715) 463-3743
Taxonomy
Speciality
Code
Description
License number
State
183500000X
Pharmacist
Primary
11821-040
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
11821-040
WISCONS PHARMACIST LICENS
WI
Enumeration date
02/07/2007
Last updated
07/08/2007
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