Provider Demographics
NPI:1487253431
Name:DOUGLAS, AMY SUE (RP)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:SUE
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:RP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8404 N 30TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68112-2270
Mailing Address - Country:US
Mailing Address - Phone:402-451-2135
Mailing Address - Fax:402-952-8032
Practice Address - Street 1:8404 N 30TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68112-2270
Practice Address - Country:US
Practice Address - Phone:402-451-2135
Practice Address - Fax:402-952-8032
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE11878183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty