Provider Demographics
NPI:1235797911
Name:HANSEN, BRIAN WILLIAM (RPH)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:WILLIAM
Last Name:HANSEN
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:N6719 HIGHWAY 42
Mailing Address - Street 2:
Mailing Address - City:ALGOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54201-9703
Mailing Address - Country:US
Mailing Address - Phone:920-559-2373
Mailing Address - Fax:
Practice Address - Street 1:N6719 HIGHWAY 42
Practice Address - Street 2:
Practice Address - City:ALGOMA
Practice Address - State:WI
Practice Address - Zip Code:54201-9703
Practice Address - Country:US
Practice Address - Phone:920-559-2373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-29
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIR7690183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist