Provider Demographics
NPI:1033494935
Name:HUBER, NICKIE L
Entity Type:Individual
Prefix:MS
First Name:NICKIE
Middle Name:L
Last Name:HUBER
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 1:5319 W 26TH ST
Mailing Address - Street 2:
Mailing Address - City:SPEEDWAY
Mailing Address - State:IN
Mailing Address - Zip Code:46224-3308
Mailing Address - Country:US
Mailing Address - Phone:317-293-4410
Mailing Address - Fax:
Practice Address - Street 1:20 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BROWNSBURG
Practice Address - State:IN
Practice Address - Zip Code:46112-1242
Practice Address - Country:US
Practice Address - Phone:317-858-7834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-12
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26013570A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist