Provider Demographics
NPI:1912244872
Name:HAM, FRED HENRY (RPH)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:HENRY
Last Name:HAM
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 1:11120 SAHLER ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-2319
Mailing Address - Country:US
Mailing Address - Phone:402-496-1675
Mailing Address - Fax:
Practice Address - Street 1:11120 SAHLER ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68164-2319
Practice Address - Country:US
Practice Address - Phone:402-496-1675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-12
Last Update Date:2013-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO28308183500000X
NE9210183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE9210OtherPHARMACIST
MO28308OtherPHARMACIST