Provider Demographics
NPI:1952688194
Name:SIMONS, MARK DEMANE (PHARM D)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DEMANE
Last Name:SIMONS
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 1:3915 BELLFLOWER ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66049-7833
Mailing Address - Country:US
Mailing Address - Phone:785-224-7647
Mailing Address - Fax:
Practice Address - Street 1:1445 S MAIN ST
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:KS
Practice Address - Zip Code:66067-3528
Practice Address - Country:US
Practice Address - Phone:785-242-4745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-15
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-14366183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist