Provider Demographics
NPI:1306168968
Name:HANSON, BERT JOHN
Entity type:Individual
Prefix:MR
First Name:BERT
Middle Name:JOHN
Last Name:HANSON
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 1:3 BROOKLINE CT
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61705-8737
Mailing Address - Country:US
Mailing Address - Phone:309-664-0741
Mailing Address - Fax:
Practice Address - Street 1:3 BROOKLINE CT
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61705-8737
Practice Address - Country:US
Practice Address - Phone:309-664-0741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-24
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.032060183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist