Provider Demographics
NPI:1033509500
Name:IDT, DONA MARIE (CPHT)
Entity type:Individual
Prefix:MS
First Name:DONA
Middle Name:MARIE
Last Name:IDT
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 N PORT WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:WI
Mailing Address - Zip Code:53024-9315
Mailing Address - Country:US
Mailing Address - Phone:262-375-6738
Mailing Address - Fax:262-618-9138
Practice Address - Street 1:1250 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WI
Practice Address - Zip Code:53024-9315
Practice Address - Country:US
Practice Address - Phone:262-375-6738
Practice Address - Fax:262-618-9138
Is Sole Proprietor?:No
Enumeration Date:2015-02-04
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI590107010293680183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician