Provider Demographics
NPI:1932130705
Name:WAXLAX, DANIEL R (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:R
Last Name:WAXLAX
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 EDISON BLVD
Mailing Address - Street 2:SUITE L
Mailing Address - City:SILVER BAY
Mailing Address - State:MN
Mailing Address - Zip Code:55614-1211
Mailing Address - Country:US
Mailing Address - Phone:218-226-3829
Mailing Address - Fax:218-226-4425
Practice Address - Street 1:99 EDISON BLVD
Practice Address - Street 2:SUITE L
Practice Address - City:SILVER BAY
Practice Address - State:MN
Practice Address - Zip Code:55614-1211
Practice Address - Country:US
Practice Address - Phone:218-226-3829
Practice Address - Fax:218-226-4425
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN113983-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist