Healthcare Provider Details

I. General information

NPI: 1720161748
Provider Name (Legal Business Name): M DOUGLAS SHAVER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 07/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 NIOBRARA AVE
HEMINGFORD NE
69348-9703
US

IV. Provider business mailing address

PO BOX 185
HEMINGFORD NE
69348-0185
US

V. Phone/Fax

Practice location:
  • Phone: 308-487-5212
  • Fax: 308-487-5235
Mailing address:
  • Phone: 308-487-5212
  • Fax: 308-487-5235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number1092
License Number StateNE

VIII. Authorized Official

Name: M DOUGLAS SHAVER
Title or Position: OWNER
Credential: RPH
Phone: 308-487-5212