Provider Demographics
NPI:1952855801
Name:AHLSTROM, DAVID MANASSEH (PHARMD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:MANASSEH
Last Name:AHLSTROM
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 S 20TH ST
Mailing Address - Street 2:
Mailing Address - City:WORLAND
Mailing Address - State:WY
Mailing Address - Zip Code:82401-3742
Mailing Address - Country:US
Mailing Address - Phone:307-347-2851
Mailing Address - Fax:307-347-2651
Practice Address - Street 1:100 S 20TH ST
Practice Address - Street 2:
Practice Address - City:WORLAND
Practice Address - State:WY
Practice Address - Zip Code:82401-3742
Practice Address - Country:US
Practice Address - Phone:307-347-2851
Practice Address - Fax:307-347-2651
Is Sole Proprietor?:No
Enumeration Date:2016-08-09
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3833183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist