Provider Demographics
NPI:1790897825
Name:DOUGLAS, MICHAEL NEWMAN (RPH)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:NEWMAN
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:MO
Mailing Address - Zip Code:65712-1004
Mailing Address - Country:US
Mailing Address - Phone:417-466-0172
Mailing Address - Fax:417-466-0196
Practice Address - Street 1:600 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:MO
Practice Address - Zip Code:65712-1004
Practice Address - Country:US
Practice Address - Phone:417-466-0172
Practice Address - Fax:417-466-0196
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO042494183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist