Provider Demographics
NPI:1104291095
Name:ERNSTHAUSEN, DALE DANIEL (RPH)
Entity type:Individual
Prefix:MR
First Name:DALE
Middle Name:DANIEL
Last Name:ERNSTHAUSEN
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 1:12720 MAHOGANY WAY
Mailing Address - Street 2:
Mailing Address - City:DEWITT
Mailing Address - State:MI
Mailing Address - Zip Code:48820-7879
Mailing Address - Country:US
Mailing Address - Phone:517-944-5614
Mailing Address - Fax:
Practice Address - Street 1:409 N MARKETPLACE BLVD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-7732
Practice Address - Country:US
Practice Address - Phone:517-622-1451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-03
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302034337183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist