Provider Demographics
NPI:1649244153
Name:DOUGLAS, DUSTIN T (PHARMD)
Entity type:Individual
Prefix:DR
First Name:DUSTIN
Middle Name:T
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:458 ASHLEY LN
Mailing Address - Street 2:
Mailing Address - City:ONEIDA
Mailing Address - State:TN
Mailing Address - Zip Code:37841-6060
Mailing Address - Country:US
Mailing Address - Phone:423-286-7825
Mailing Address - Fax:
Practice Address - Street 1:19 MEDICAL LOOP STE 2
Practice Address - Street 2:
Practice Address - City:WHITLEY CITY
Practice Address - State:KY
Practice Address - Zip Code:42653-4382
Practice Address - Country:US
Practice Address - Phone:606-376-5043
Practice Address - Fax:606-376-5466
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2024-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0036725183500000X
TN36725183500000X
KY016194183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist