Provider Demographics
NPI:1225311228
Name:FAHRNER, DANIEL LEE
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:LEE
Last Name:FAHRNER
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 1:218 MEADOW WOOD DR
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60431-4810
Mailing Address - Country:US
Mailing Address - Phone:815-725-7701
Mailing Address - Fax:815-730-8677
Practice Address - Street 1:2379 PLAINFIELD RD
Practice Address - Street 2:
Practice Address - City:CREST HILL
Practice Address - State:IL
Practice Address - Zip Code:60403-1848
Practice Address - Country:US
Practice Address - Phone:815-730-8663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-26
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051034795183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist