Provider Demographics
NPI:1780344085
Name:SUTHERLAND, DANA
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:SUTHERLAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 COUNTRYSIDE EST SW
Mailing Address - Street 2:
Mailing Address - City:WAUKON
Mailing Address - State:IA
Mailing Address - Zip Code:52172-7500
Mailing Address - Country:US
Mailing Address - Phone:563-568-7086
Mailing Address - Fax:
Practice Address - Street 1:21 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WAUKON
Practice Address - State:IA
Practice Address - Zip Code:52172-1637
Practice Address - Country:US
Practice Address - Phone:563-568-6315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-28
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20086-40183500000X
IA23104183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist