Provider Demographics
NPI:1225071731
Name:KANAK, DALE E (RPH)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:E
Last Name:KANAK
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:W3559 MEREDITH LN
Mailing Address - Street 2:
Mailing Address - City:GREEN LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54941-9650
Mailing Address - Country:US
Mailing Address - Phone:920-295-6233
Mailing Address - Fax:920-295-4556
Practice Address - Street 1:822 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:WI
Practice Address - Zip Code:54923-1300
Practice Address - Country:US
Practice Address - Phone:920-361-3433
Practice Address - Fax:920-361-0235
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12591-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist