Provider Demographics
NPI:1366569501
Name:WINDER, CRAIG A
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:A
Last Name:WINDER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4136 KELLING CT
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52806-4800
Mailing Address - Country:US
Mailing Address - Phone:563-391-2688
Mailing Address - Fax:
Practice Address - Street 1:2200 W KIMBERLY RD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52806-5300
Practice Address - Country:US
Practice Address - Phone:563-391-1543
Practice Address - Fax:563-391-9117
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA16833183500000X
WI8272183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0047746Medicaid