Provider Demographics
NPI:1770187973
Name:EMANUEL, DYLAN R
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:R
Last Name:EMANUEL
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 1:500 CLIFTY DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:IN
Mailing Address - Zip Code:47250-1609
Mailing Address - Country:US
Mailing Address - Phone:812-273-2117
Mailing Address - Fax:
Practice Address - Street 1:500 CLIFTY DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:IN
Practice Address - Zip Code:47250-1609
Practice Address - Country:US
Practice Address - Phone:812-273-2117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-28
Last Update Date:2020-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26027409A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist