Provider Demographics
NPI:1023188752
Name:HANSEN, JERRY C
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:C
Last Name:HANSEN
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 1:1642 14TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-9111
Mailing Address - Country:US
Mailing Address - Phone:701-839-0156
Mailing Address - Fax:
Practice Address - Street 1:1 BURDICK EXPY W
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-4406
Practice Address - Country:US
Practice Address - Phone:701-857-5550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND3756183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist