Provider Demographics
NPI:1477164762
Name:HANEL, MACEY RAELYNN (PHARMD)
Entity Type:Individual
Prefix:
First Name:MACEY
Middle Name:RAELYNN
Last Name:HANEL
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:MACEY
Other - Middle Name:RAELYNN
Other - Last Name:LLEWELLYN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2400 32ND AVE S STE 4
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-5804
Mailing Address - Country:US
Mailing Address - Phone:701-234-9912
Mailing Address - Fax:
Practice Address - Street 1:2400 32ND AVE S STE 4
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-5804
Practice Address - Country:US
Practice Address - Phone:701-234-9912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-11
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDRPH6135183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist