Provider Demographics
NPI:1619218286
Name:ROUSSELLE, ALAN DUANE
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:DUANE
Last Name:ROUSSELLE
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 1:5056 CR 4500
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:KS
Mailing Address - Zip Code:67301-7569
Mailing Address - Country:US
Mailing Address - Phone:620-515-1945
Mailing Address - Fax:
Practice Address - Street 1:301 W MAIN ST
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:KS
Practice Address - Zip Code:67301-3514
Practice Address - Country:US
Practice Address - Phone:620-331-7594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-07
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS09710183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist