Provider Demographics
NPI:1770030488
Name:ALLEN, DUANE (RPH)
Entity Type:Individual
Prefix:MR
First Name:DUANE
Middle Name:
Last Name:ALLEN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:429 MUNSON PL APT 8
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-3065
Mailing Address - Country:US
Mailing Address - Phone:307-321-9009
Mailing Address - Fax:231-258-5488
Practice Address - Street 1:784 SOUTH CEDAR ST STE E
Practice Address - Street 2:
Practice Address - City:KALKASKA
Practice Address - State:MI
Practice Address - Zip Code:49646
Practice Address - Country:US
Practice Address - Phone:307-324-5276
Practice Address - Fax:307-324-5277
Is Sole Proprietor?:No
Enumeration Date:2016-09-10
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3817183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1770030488Other1770030488
WY1770030488Medicaid