Provider Demographics
NPI:1932481710
Name:GRAHAM, DONALD BRUCE (RPH)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:BRUCE
Last Name:GRAHAM
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 1:205 W 27TH ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-4307
Mailing Address - Country:US
Mailing Address - Phone:308-635-3296
Mailing Address - Fax:308-635-3891
Practice Address - Street 1:205 W 27TH ST
Practice Address - Street 2:
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-4307
Practice Address - Country:US
Practice Address - Phone:308-635-3296
Practice Address - Fax:308-635-3891
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-16
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE8461183500000X
CO12203183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist