Provider Demographics
NPI:1215488788
Name:CANCER SPECIALTY PHARMACY LLC
Entity type:Organization
Organization Name:CANCER SPECIALTY PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:DARLA
Authorized Official - Middle Name:R
Authorized Official - Last Name:DUREE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:402-334-6100
Mailing Address - Street 1:17545 GOLD PLAZA
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68130
Mailing Address - Country:US
Mailing Address - Phone:402-334-6100
Mailing Address - Fax:402-334-6118
Practice Address - Street 1:17545 GOLD PLZ
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68130-5602
Practice Address - Country:US
Practice Address - Phone:402-334-6100
Practice Address - Fax:402-334-6118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-20
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NE6793336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2164614OtherPK
2164614OtherPK