=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073985362
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONATHON LAMARQUE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2015
-----------------------------------------------------
Last Update Date | 02/13/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18780 S 68TH ST STE B
-----------------------------------------------------
City | HICKMAN
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68372-7083
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-792-0006
-----------------------------------------------------
Fax | 402-792-0010
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6510 BEAVER CREEK LN
-----------------------------------------------------
City | LINCOLN
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68516-3347
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-277-1871
-----------------------------------------------------
Fax | 402-792-0010
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 14563
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------