Provider Demographics
NPI:1548454937
Name:FORNOFF, ANISA (PHARMD)
Entity type:Individual
Prefix:DR
First Name:ANISA
Middle Name:
Last Name:FORNOFF
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2507 UNIVERSITY AVE
Mailing Address - Street 2:DRAKE UNIVERSITY-CLINE 106
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50311-4516
Mailing Address - Country:US
Mailing Address - Phone:515-557-1810
Mailing Address - Fax:515-557-1809
Practice Address - Street 1:5518 NW 88TH ST
Practice Address - Street 2:DRAKE PHARMACY
Practice Address - City:JOHNSTON
Practice Address - State:IA
Practice Address - Zip Code:50131-1782
Practice Address - Country:US
Practice Address - Phone:515-557-1810
Practice Address - Fax:515-557-1809
Is Sole Proprietor?:No
Enumeration Date:2007-08-29
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA19695183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist