Provider Demographics
NPI:1295347607
Name:HANNA, MICHAEL
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:HANNA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5455 ROBERTS ST
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:KS
Mailing Address - Zip Code:66226-3937
Mailing Address - Country:US
Mailing Address - Phone:913-667-1728
Mailing Address - Fax:
Practice Address - Street 1:5455 ROBERTS ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:KS
Practice Address - Zip Code:66226-3937
Practice Address - Country:US
Practice Address - Phone:913-667-1728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-105713183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1-105713Medicaid