MEDICARE: DOUGLAS CORNELIUS RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	19370	OH

General Provider Information

NPI Number	:	1700422524
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOUGLAS CORNELIUS RPH

Provider Business Mailing Address
First Line	:	4435 KAUFFMAN RD
Second Line	:
City	:	PLAIN CITY
State	:	OH
Zip	:	43064-9235
Country	:	US
Telephone Number	:	614-719-9066
Fax Number	:

Provider Business Practice Location Address
First Line	:	4435 KAUFFMAN RD
Second Line	:
City	:	PLAIN CITY
State	:	OH
Zip	:	43064-9235
Country	:	US
Telephone Number	:	614-719-9066
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/27/2019
Last Update Date	:	11/27/2019

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