Provider Demographics
NPI:1043400112
Name:LANDERS, NICK L (PD)
Entity Type:Individual
Prefix:DR
First Name:NICK
Middle Name:L
Last Name:LANDERS
Suffix:
Gender:M
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 HUNTINGTON EST
Mailing Address - Street 2:
Mailing Address - City:BRYANT
Mailing Address - State:AR
Mailing Address - Zip Code:72022-2961
Mailing Address - Country:US
Mailing Address - Phone:501-847-0679
Mailing Address - Fax:501-315-4136
Practice Address - Street 1:414 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-3714
Practice Address - Country:US
Practice Address - Phone:501-315-7700
Practice Address - Fax:501-315-4136
Is Sole Proprietor?:No
Enumeration Date:2007-07-25
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR5998183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist