Provider Demographics
NPI:1417372376
Name:DAUGHERTY, ANGELA LYNN (PHARMD)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:LYNN
Last Name:DAUGHERTY
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 1:1800 S JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:MO
Mailing Address - Zip Code:65536-4208
Mailing Address - Country:US
Mailing Address - Phone:417-532-7148
Mailing Address - Fax:417-532-2631
Practice Address - Street 1:1800 S JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-4208
Practice Address - Country:US
Practice Address - Phone:417-532-7148
Practice Address - Fax:417-532-2631
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-28
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO044865183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist