Provider Demographics
NPI:1073523932
Name:NICKLAS, DAVID EUGENE (DPH)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:EUGENE
Last Name:NICKLAS
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1807 HENSON CT
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-4240
Mailing Address - Country:US
Mailing Address - Phone:405-275-6169
Mailing Address - Fax:
Practice Address - Street 1:1442 N HARRISON ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801-5208
Practice Address - Country:US
Practice Address - Phone:405-273-9906
Practice Address - Fax:405-273-4329
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK9416183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist