Healthcare Provider Details

I. General information

NPI: 1972592913
Provider Name (Legal Business Name): MARCUS VICTOR THOENDEL RP
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11134 Q ST
OMAHA NE
68137-3609
US

IV. Provider business mailing address

9710 MELISSA ST
LAVISTA NE
68128-4230
US

V. Phone/Fax

Practice location:
  • Phone: 402-592-5244
  • Fax: 402-592-2501
Mailing address:
  • Phone: 402-614-9565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number11879
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: