Provider Demographics
NPI:1043627995
Name:ANDERSON, DANE RYAN
Entity Type:Individual
Prefix:MR
First Name:DANE
Middle Name:RYAN
Last Name:ANDERSON
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 1:1510 OHIO ST
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:KS
Mailing Address - Zip Code:67010-2157
Mailing Address - Country:US
Mailing Address - Phone:316-775-5456
Mailing Address - Fax:316-775-4108
Practice Address - Street 1:1510 OHIO ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:KS
Practice Address - Zip Code:67010-2157
Practice Address - Country:US
Practice Address - Phone:316-775-5456
Practice Address - Fax:316-775-4108
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-11
Last Update Date:2014-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11779183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist