Basic Information
| Provider Information | |||||||||
| NPI: | 1043627995 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | DANE | ||||||||
| MiddleName: | RYAN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1510 OHIO ST | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 670102157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3167755456 | ||||||||
| FaxNumber: | 3167754108 | ||||||||
| Practice Location | |||||||||
| Address1: | 1510 OHIO ST | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 670102157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3167755456 | ||||||||
| FaxNumber: | 3167754108 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2014 | ||||||||
| LastUpdateDate: | 07/11/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 11779 | KS | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.