Provider Demographics
NPI:1932498557
Name:HANSON, DWANE LYLE (RPH)
Entity Type:Individual
Prefix:
First Name:DWANE
Middle Name:LYLE
Last Name:HANSON
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:PO BOX 61402
Mailing Address - Street 2:1704 DAVIS AVE
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98666-1402
Mailing Address - Country:US
Mailing Address - Phone:503-516-9946
Mailing Address - Fax:
Practice Address - Street 1:1235 WAVERLY DR SE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97322-6944
Practice Address - Country:US
Practice Address - Phone:541-928-8668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-05
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6611183500000X
WAPH60060820183500000X
AZS017817183500000X
TX24695183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist