Provider Demographics
NPI:1588726392
Name:SEVERSON, DAN L (RPH)
Entity type:Individual
Prefix:
First Name:DAN
Middle Name:L
Last Name:SEVERSON
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 1:301 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STEVENSVILLE
Mailing Address - State:MT
Mailing Address - Zip Code:59870-2531
Mailing Address - Country:US
Mailing Address - Phone:406-777-5591
Mailing Address - Fax:406-777-5150
Practice Address - Street 1:301 MAIN ST
Practice Address - Street 2:
Practice Address - City:STEVENSVILLE
Practice Address - State:MT
Practice Address - Zip Code:59870-2531
Practice Address - Country:US
Practice Address - Phone:406-777-5591
Practice Address - Fax:406-777-5150
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT2436183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist