Provider Demographics
NPI:1629288527
Name:DOUGLASS, DEANNA RAE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:DEANNA
Middle Name:RAE
Last Name:DOUGLASS
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 1:426 CATHRINE CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:IL
Mailing Address - Zip Code:62236-2745
Mailing Address - Country:US
Mailing Address - Phone:618-281-5463
Mailing Address - Fax:
Practice Address - Street 1:426 CATHRINE CT
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:IL
Practice Address - Zip Code:62236-2745
Practice Address - Country:US
Practice Address - Phone:618-281-5463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO045089183500000X
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist