MEDICARE: MEDICATION THERAPY MANAGEMENT

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	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	9752	NE

General Provider Information

NPI Number	:	1700322393
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDICATION THERAPY MANAGEMENT

Provider Business Mailing Address
First Line	:	2631 N 157TH ST
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68116-2029
Country	:	US
Telephone Number	:	402-651-6724
Fax Number	:

Provider Business Practice Location Address
First Line	:	2631 N 157TH ST
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68116-2029
Country	:	US
Telephone Number	:	402-651-6724
Fax Number	:

Authorized Official
Title or Position	:	TOBACCO CESSATION COUNSELOR
Name	:	DR. KENNETH SAUNDERS
Credential	:	PHARMD.
Telephone Number	:	402-651-6724

Provider Enumeration Date	:	01/06/2017
Last Update Date	:	01/06/2017

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