Healthcare Provider Details

I. General information

NPI: 1427179480
Provider Name (Legal Business Name): DONALD. FAGAN R.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 N 30TH ST
OMAHA NE
68131-2137
US

IV. Provider business mailing address

6665 N 168TH ST
OMAHA NE
68116-5210
US

V. Phone/Fax

Practice location:
  • Phone: 402-449-4570
  • Fax: 402-449-5538
Mailing address:
  • Phone: 402-449-4570
  • Fax: 402-449-5538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number8333
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: