Provider Demographics
NPI:1497807929
Name:RASMUSSEN, DANE L (RPH)
Entity type:Individual
Prefix:MR
First Name:DANE
Middle Name:L
Last Name:RASMUSSEN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 15
Mailing Address - Street 2:281 HIGHWAY 63
Mailing Address - City:BALDWIN
Mailing Address - State:WI
Mailing Address - Zip Code:54002-0015
Mailing Address - Country:US
Mailing Address - Phone:715-684-2825
Mailing Address - Fax:715-684-4076
Practice Address - Street 1:840 MAIN ST.
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:WI
Practice Address - Zip Code:54002
Practice Address - Country:US
Practice Address - Phone:715-684-2825
Practice Address - Fax:715-684-4076
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9469040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33079900Medicaid
WI33079900Medicaid