Provider Demographics
NPI:1164790374
Name:DOUAH, EMMANUEL (RPH)
Entity Type:Individual
Prefix:MR
First Name:EMMANUEL
Middle Name:
Last Name:DOUAH
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1523 PHEASANTWOOD TRL
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55057-3019
Mailing Address - Country:US
Mailing Address - Phone:612-229-8367
Mailing Address - Fax:
Practice Address - Street 1:612 4TH AVENUE NW
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021
Practice Address - Country:US
Practice Address - Phone:507-332-9783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-02
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN117100183500000X
MA245453183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist