=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326738790
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THANE C DRIER PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2023
-----------------------------------------------------
Last Update Date | 06/28/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 711 W ADAMS ST
-----------------------------------------------------
City | BLACK RIVER FALLS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54615-5052
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-284-1323
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | E12730 BIRCH TREE LN
-----------------------------------------------------
City | FALL CREEK
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54742-4310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-579-7308
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 13959-40
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------