Provider Demographics
NPI:1720400328
Name:HANSON, KIERSTAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:KIERSTAN
Middle Name:
Last Name:HANSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10627 DIEBOLD RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-8606
Mailing Address - Country:US
Mailing Address - Phone:260-240-2745
Mailing Address - Fax:
Practice Address - Street 1:611 E DOUGLAS RD
Practice Address - Street 2:SUITE 412
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1464
Practice Address - Country:US
Practice Address - Phone:574-335-6503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-16
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53020393661835P1200X
IN26022910A1835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy