Provider Demographics
NPI:1558013409
Name:STAAB, MIRANDA
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:STAAB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 S 184TH CT APT 104
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:NE
Mailing Address - Zip Code:68022-5779
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7500 MERCY RD
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-2319
Practice Address - Country:US
Practice Address - Phone:402-717-1165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-21
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE16876183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty