Provider Demographics
NPI:1770747727
Name:HANSON, CAROLYN MARY (RPH)
Entity type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:MARY
Last Name:HANSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 189
Mailing Address - Street 2:
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-0189
Mailing Address - Country:US
Mailing Address - Phone:906-774-3654
Mailing Address - Fax:906-774-5502
Practice Address - Street 1:1112 S. STEPHENSON AVE.
Practice Address - Street 2:
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-0189
Practice Address - Country:US
Practice Address - Phone:906-774-3654
Practice Address - Fax:906-774-5502
Is Sole Proprietor?:No
Enumeration Date:2008-07-17
Last Update Date:2009-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302411095183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302411095OtherBOARD OF PHARMACY