=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770747727
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAROLYN MARY HANSON RPH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2008
-----------------------------------------------------
Last Update Date | 09/25/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1112 S. STEPHENSON AVE.
-----------------------------------------------------
City | IRON MOUNTAIN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49801-0189
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 906-774-3654
-----------------------------------------------------
Fax | 906-774-5502
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 189
-----------------------------------------------------
City | IRON MOUNTAIN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49801-0189
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 906-774-3654
-----------------------------------------------------
Fax | 906-774-5502
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 5302411095
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------