Provider Demographics
NPI:1619386851
Name:POULSEN, DALLIN D (PHARMD, MBA/HSA)
Entity Type:Individual
Prefix:
First Name:DALLIN
Middle Name:D
Last Name:POULSEN
Suffix:
Gender:M
Credentials:PHARMD, MBA/HSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2626 S CORBIN CIR
Mailing Address - Street 2:
Mailing Address - City:GREENACRES
Mailing Address - State:WA
Mailing Address - Zip Code:99016-7719
Mailing Address - Country:US
Mailing Address - Phone:507-206-8087
Mailing Address - Fax:
Practice Address - Street 1:2626 S CORBIN CIR
Practice Address - Street 2:
Practice Address - City:GREENACRES
Practice Address - State:WA
Practice Address - Zip Code:99016-7719
Practice Address - Country:US
Practice Address - Phone:507-206-8087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-12
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53020384251835P0018X
IDP66141835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist