Provider Demographics
NPI:1154929370
Name:SMITH, DANIEL
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7280 E POINT DOUGLAS RD S
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55016-3016
Mailing Address - Country:US
Mailing Address - Phone:651-458-7002
Mailing Address - Fax:
Practice Address - Street 1:7280 E POINT DOUGLAS RD S
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55016-3016
Practice Address - Country:US
Practice Address - Phone:651-458-7002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN123676183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN123676OtherSTATE LICENSE NUMBER