Provider Demographics
NPI:1063302990
Name:NICOLET PHARMACY LONG TERM CARE
Entity type:Organization
Organization Name:NICOLET PHARMACY LONG TERM CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:J
Authorized Official - Last Name:DONALDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-276-3646
Mailing Address - Street 1:15481 COMMERCIAL RD STE A
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WI
Mailing Address - Zip Code:54138-9677
Mailing Address - Country:US
Mailing Address - Phone:715-276-3646
Mailing Address - Fax:715-276-9568
Practice Address - Street 1:15481 COMMERCIAL RD STE A
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WI
Practice Address - Zip Code:54138-9677
Practice Address - Country:US
Practice Address - Phone:715-276-3646
Practice Address - Fax:715-276-9568
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NICOLET PHARMACY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-07-03
Last Update Date:2025-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy