Provider Demographics
NPI:1265718779
Name:MADSEN, ROXANNE R
Entity type:Individual
Prefix:
First Name:ROXANNE
Middle Name:R
Last Name:MADSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7828 S 91ST CIR
Mailing Address - Street 2:
Mailing Address - City:LA VISTA
Mailing Address - State:NE
Mailing Address - Zip Code:68128-4216
Mailing Address - Country:US
Mailing Address - Phone:402-339-8371
Mailing Address - Fax:
Practice Address - Street 1:6905 S 36TH ST
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:NE
Practice Address - Zip Code:68147-1231
Practice Address - Country:US
Practice Address - Phone:402-734-7592
Practice Address - Fax:402-734-5784
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-28
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE10278183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist