Provider Demographics
NPI:1639388168
Name:HANSEN, CODY KIM (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:CODY
Middle Name:KIM
Last Name:HANSEN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3611 DUCATI WAY
Mailing Address - Street 2:
Mailing Address - City:SAINT GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-6635
Mailing Address - Country:US
Mailing Address - Phone:435-668-5898
Mailing Address - Fax:435-674-2963
Practice Address - Street 1:3611 DUCATI WAY
Practice Address - Street 2:
Practice Address - City:SAINT GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-6635
Practice Address - Country:US
Practice Address - Phone:435-668-5898
Practice Address - Fax:435-674-2963
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5725931-8911183500000X
NV16444183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist