Healthcare Provider Details

I. General information

NPI: 1093131757
Provider Name (Legal Business Name): ALAN D LANE RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2014
Last Update Date: 03/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

386 E PINE ST
BOURBON MO
65441-7506
US

IV. Provider business mailing address

599 HIGHWAY DD APT 6
CUBA MO
65454
US

V. Phone/Fax

Practice location:
  • Phone: 573-732-4418
  • Fax: 573-732-3640
Mailing address:
  • Phone: 573-415-6081
  • Fax: 573-732-3640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2011005721
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: