Provider Demographics
NPI:1972006310
Name:FAIRBANKS, DANIELLE R
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:R
Last Name:FAIRBANKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:R
Other - Last Name:FAIRBANKS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARMD
Mailing Address - Street 1:163 OSPREY LANE
Mailing Address - Street 2:
Mailing Address - City:BLUE EYE
Mailing Address - State:MO
Mailing Address - Zip Code:65611
Mailing Address - Country:US
Mailing Address - Phone:402-995-9506
Mailing Address - Fax:
Practice Address - Street 1:101 INDUSTRIAL PARK DRIVE
Practice Address - Street 2:
Practice Address - City:HOLLISTER
Practice Address - State:MO
Practice Address - Zip Code:65672
Practice Address - Country:US
Practice Address - Phone:417-336-6901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-12
Last Update Date:2022-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA22336183500000X
NE14591183500000X
MO2019044157183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist