Provider Demographics
NPI:1003416272
Name:SMALL, JACQUELINE J (PHARMD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:J
Last Name:SMALL
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4805 FOUNTAIN CIR
Mailing Address - Street 2:
Mailing Address - City:PAPILLION
Mailing Address - State:NE
Mailing Address - Zip Code:68133-4726
Mailing Address - Country:US
Mailing Address - Phone:402-639-3986
Mailing Address - Fax:
Practice Address - Street 1:11650 S 73RD ST
Practice Address - Street 2:
Practice Address - City:PAPILLION
Practice Address - State:NE
Practice Address - Zip Code:68046-1500
Practice Address - Country:US
Practice Address - Phone:402-597-5056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE11887183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist