Provider Demographics
NPI:1699140061
Name:IVANSON, DARRYL (RPH)
Entity type:Individual
Prefix:
First Name:DARRYL
Middle Name:
Last Name:IVANSON
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 1:407 FOXRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47462-5024
Mailing Address - Country:US
Mailing Address - Phone:812-583-3962
Mailing Address - Fax:812-277-1259
Practice Address - Street 1:407 FOXRIDGE DR
Practice Address - Street 2:
Practice Address - City:SPRINGVILLE
Practice Address - State:IN
Practice Address - Zip Code:47462-5024
Practice Address - Country:US
Practice Address - Phone:812-583-3962
Practice Address - Fax:812-277-1259
Is Sole Proprietor?:No
Enumeration Date:2015-12-10
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050689-1183500000X
IN26018275A183500000X
IL051.290856183500000X
OHRPH.03226607-2183500000X
CA32379183500000X
WI16918-40183500000X
UT8243223-1701183500000X
PARP446558183500000X
WY3602183500000X
MTPHA-PHA-LIC-14205183500000X
KY015983183500000X
FLPS40894183500000X
GARPH023032183500000X
NV11578183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist