Healthcare Provider Details

I. General information

NPI: 1376132902
Provider Name (Legal Business Name): RICHARD L DOUGLASS RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2021
Last Update Date: 01/18/2021
Certification Date: 01/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35279 VINE ST
WILLOWICK OH
44095-3140
US

IV. Provider business mailing address

25077 MAIDSTONE LN
BEACHWOOD OH
44122-1770
US

V. Phone/Fax

Practice location:
  • Phone: 440-918-0700
  • Fax:
Mailing address:
  • Phone: 216-849-3025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number03218162
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: