Provider Demographics
NPI:1104038694
Name:DANIEL, TANJA RAE (RPH)
Entity Type:Individual
Prefix:
First Name:TANJA
Middle Name:RAE
Last Name:DANIEL
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3017 MAYOWOOD COMMON CR SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55902
Mailing Address - Country:US
Mailing Address - Phone:507-285-9120
Mailing Address - Fax:
Practice Address - Street 1:1216 2ND ST SW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55902
Practice Address - Country:US
Practice Address - Phone:507-255-5731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN116602183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist