Provider Demographics
NPI:1194152108
Name:KLEVELAND, DANA JON (RPH)
Entity type:Individual
Prefix:MR
First Name:DANA
Middle Name:JON
Last Name:KLEVELAND
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 1:1300 S KOELLER ST
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54902-6169
Mailing Address - Country:US
Mailing Address - Phone:920-426-5770
Mailing Address - Fax:920-426-1708
Practice Address - Street 1:1300 S KOELLER ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54902-6169
Practice Address - Country:US
Practice Address - Phone:920-426-5770
Practice Address - Fax:920-426-1708
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-04
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10920-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist