Healthcare Provider Details

I. General information

NPI: 1104859693
Provider Name (Legal Business Name): ELIZABETH MARIE PORTER PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 04/10/2025
Certification Date: 04/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

923 SENIOR CIR
MACY NE
68039-4018
US

IV. Provider business mailing address

104 HANKS WAY
SOUTH SIOUX CITY NE
68776-5460
US

V. Phone/Fax

Practice location:
  • Phone: 402-837-4358
  • Fax: 402-837-5381
Mailing address:
  • Phone: 402-385-8043
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number12435
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: