Provider Demographics
NPI:1124410931
Name:NONE
Entity Type:Organization
Organization Name:NONE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:HANER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:970-290-6802
Mailing Address - Street 1:1232 E 20TH ST
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-4019
Mailing Address - Country:US
Mailing Address - Phone:970-290-6802
Mailing Address - Fax:
Practice Address - Street 1:1232 E 20TH ST
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-4019
Practice Address - Country:US
Practice Address - Phone:970-290-6802
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-03
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO11824333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy