Provider Demographics
NPI:1922214113
Name:HANSEN, JACK C (PHARM D)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:C
Last Name:HANSEN
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1309 ELM ST
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC
Mailing Address - State:IA
Mailing Address - Zip Code:50022-2335
Mailing Address - Country:US
Mailing Address - Phone:712-243-7717
Mailing Address - Fax:
Practice Address - Street 1:1630 E 7TH ST
Practice Address - Street 2:
Practice Address - City:ATLANTIC
Practice Address - State:IA
Practice Address - Zip Code:50022-1909
Practice Address - Country:US
Practice Address - Phone:712-243-2240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA20468183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist