Healthcare Provider Details

I. General information

NPI: 1295380202
Provider Name (Legal Business Name): DYLAN DONER PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2019
Last Update Date: 08/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 STATE ROAD 26 E
LAFAYETTE IN
47905-4611
US

IV. Provider business mailing address

404 BRUNSWICK DR APT 13
LAFAYETTE IN
47909-6979
US

V. Phone/Fax

Practice location:
  • Phone: 765-449-9210
  • Fax: 765-449-9265
Mailing address:
  • Phone: 765-993-7658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26028320A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: