Basic Information
| Provider Information | |||||||||
| NPI: | 1104038694 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DANIEL | ||||||||
| FirstName: | TANJA | ||||||||
| MiddleName: | RAE | ||||||||
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| Credential: | RPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3017 MAYOWOOD COMMON CR SW | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5072859120 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1216 2ND ST SW | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5072555731 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 116602 | MN | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.