Provider Demographics
NPI:1164831491
Name:SMALL, CHANDA MARIE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:CHANDA
Middle Name:MARIE
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 1:1710 S 70TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506-1682
Mailing Address - Country:US
Mailing Address - Phone:402-484-0912
Mailing Address - Fax:402-484-0800
Practice Address - Street 1:1710 S 70TH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506
Practice Address - Country:US
Practice Address - Phone:402-484-0912
Practice Address - Fax:402-484-0800
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-12
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-16462183500000X
NE15661183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE15661OtherNEBRASKA PHARMACIST LICENSE
KS1-16462OtherKANSAS PHARMACY LICENSE