MEDICARE: DR. KEBRA RENEE MCDOUGAL 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	67514	TX

General Provider Information

NPI Number	:	1538761200
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEBRA RENEE MCDOUGAL PHARMD

Provider Business Mailing Address
First Line	:	2051 W CUMBERLAND RD APT 712
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75703-7853
Country	:	US
Telephone Number	:	903-316-3000
Fax Number	:

Provider Business Practice Location Address
First Line	:	110 S SW LOOP 323
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75702-6508
Country	:	US
Telephone Number	:	903-526-5361
Fax Number	:

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

Provider Enumeration Date	:	11/09/2020
Last Update Date	:	11/09/2020

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