MEDICARE: DR. DEANJ DAVID WILLSON JR. PHARMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	11812	NE

General Provider Information

NPI Number	:	1437471729
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DEANJ DAVID WILLSON JR. PHARMD

Provider Business Mailing Address
First Line	:	15947 YATES ST
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68116-2435
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5000 L ST
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68117-1329
Country	:	US
Telephone Number	:	402-733-6935
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/27/2010
Last Update Date	:	02/27/2010

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