Provider Demographics
NPI:1710263702
Name:FOUNTAIN, DAWN C (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:DAWN
Middle Name:C
Last Name:FOUNTAIN
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 1:5801 S 167TH AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68135-2397
Mailing Address - Country:US
Mailing Address - Phone:402-740-8413
Mailing Address - Fax:
Practice Address - Street 1:5062 S 155TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-5002
Practice Address - Country:US
Practice Address - Phone:402-861-6966
Practice Address - Fax:402-861-6966
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-23
Last Update Date:2011-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE9878183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE9878OtherSTATE ID