Provider Demographics
NPI:1679248868
Name:DOUGLASS, ALICIA RAE (PHARMD)
Entity Type:Individual
Prefix:
First Name:ALICIA
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 1:2820 E ANDY DEVINE AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-4203
Mailing Address - Country:US
Mailing Address - Phone:928-753-2226
Mailing Address - Fax:
Practice Address - Street 1:2820 E ANDY DEVINE AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-4290
Practice Address - Country:US
Practice Address - Phone:928-753-2226
Practice Address - Fax:928-753-7649
Is Sole Proprietor?:No
Enumeration Date:2021-08-10
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS024639183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist