Provider Demographics
NPI:1093131757
Name:LANE, ALAN D (RPH)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:D
Last Name:LANE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:599 HIGHWAY DD APT 6
Mailing Address - Street 2:
Mailing Address - City:CUBA
Mailing Address - State:MO
Mailing Address - Zip Code:65454
Mailing Address - Country:US
Mailing Address - Phone:573-415-6081
Mailing Address - Fax:573-732-3640
Practice Address - Street 1:386 E PINE ST
Practice Address - Street 2:
Practice Address - City:BOURBON
Practice Address - State:MO
Practice Address - Zip Code:65441-7506
Practice Address - Country:US
Practice Address - Phone:573-732-4418
Practice Address - Fax:573-732-3640
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-05
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011005721183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist