Provider Demographics
NPI:1013603117
Name:DETTMAN, IAN CIRASUNDA (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:CIRASUNDA
Last Name:DETTMAN
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 1:2000 E TAMARACK RD # 5-502
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-9766
Mailing Address - Country:US
Mailing Address - Phone:951-520-6761
Mailing Address - Fax:
Practice Address - Street 1:301 N 1ST ST BLDG 46
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73523-5004
Practice Address - Country:US
Practice Address - Phone:580-481-5224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-12
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COIN.0002008403183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist