Provider Demographics
NPI:1083212906
Name:HORN, DANIEL JAMES
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:JAMES
Last Name:HORN
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 1:1415 LAWRENCE DR
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-3927
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1415 LAWRENCE DR
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-3927
Practice Address - Country:US
Practice Address - Phone:920-336-7168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16510-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist