Provider Demographics
NPI:1700425238
Name:DOUGLAS, EZRA (PHARMD)
Entity type:Individual
Prefix:
First Name:EZRA
Middle Name:
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 1:939 ANGULAR ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:IA
Mailing Address - Zip Code:52601-3918
Mailing Address - Country:US
Mailing Address - Phone:319-753-0112
Mailing Address - Fax:
Practice Address - Street 1:939 ANGULAR ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:IA
Practice Address - Zip Code:52601-3918
Practice Address - Country:US
Practice Address - Phone:319-753-0112
Practice Address - Fax:319-753-0113
Is Sole Proprietor?:No
Enumeration Date:2020-01-01
Last Update Date:2020-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA19975183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist