Healthcare Provider Details

I. General information

NPI: 1528063971
Provider Name (Legal Business Name): KELLY OLSSON CROMER PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2005
Last Update Date: 09/20/2017
Certification Date:
Deactivation Date: 07/17/2007
Reactivation Date: 09/20/2017

III. Provider practice location address

PO BOX 250
MACY NE
68039-0250
US

IV. Provider business mailing address

15206 GROVER ST
OMAHA NE
68144-5447
US

V. Phone/Fax

Practice location:
  • Phone: 402-837-5381
  • Fax: 402-837-4358
Mailing address:
  • Phone: 402-359-1004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number11831
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number13101
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: