Provider Demographics
NPI:1851681084
Name:HANSEN, MARK RICHARD (RPH)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:RICHARD
Last Name:HANSEN
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 1:312 S. JAMES ST.
Mailing Address - Street 2:RITE AID PHARMACY #02753
Mailing Address - City:GRAYLING
Mailing Address - State:MI
Mailing Address - Zip Code:49738
Mailing Address - Country:US
Mailing Address - Phone:989-348-1350
Mailing Address - Fax:
Practice Address - Street 1:312 S JAMES ST
Practice Address - Street 2:
Practice Address - City:GRAYLING
Practice Address - State:MI
Practice Address - Zip Code:49738-1818
Practice Address - Country:US
Practice Address - Phone:989-348-1350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-08
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302021293183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist