Provider Demographics
NPI:1245881309
Name:SMITH, DAN ROBERT
Entity type:Individual
Prefix:
First Name:DAN
Middle Name:ROBERT
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DAN
Other - Middle Name:ROBERT
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:19515 BRUNE PKWY
Mailing Address - Street 2:
Mailing Address - City:WARRENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63383-6505
Mailing Address - Country:US
Mailing Address - Phone:636-235-4049
Mailing Address - Fax:
Practice Address - Street 1:19515 BRUNE PKWY
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:MO
Practice Address - Zip Code:63383-6505
Practice Address - Country:US
Practice Address - Phone:636-235-4049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-20
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO041880183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist