Provider Demographics
NPI:1194204255
Name:HANSEN, TODD CARLTON
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:CARLTON
Last Name:HANSEN
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 1:1102 KILLARNEY AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6845
Mailing Address - Country:US
Mailing Address - Phone:208-390-9100
Mailing Address - Fax:
Practice Address - Street 1:3250 MIDWAY DR
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-7650
Practice Address - Country:US
Practice Address - Phone:208-552-7677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-09
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5256183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist