Provider Demographics
NPI:1083992770
Name:NYSTROM, ELAINE CAROL
Entity Type:Individual
Prefix:MISS
First Name:ELAINE
Middle Name:CAROL
Last Name:NYSTROM
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 1:3573 HILLSBOROUGH ROAD
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-2916
Mailing Address - Country:US
Mailing Address - Phone:919-383-0171
Mailing Address - Fax:919-384-9641
Practice Address - Street 1:3573 HILLSBOROUGH ROAD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-2916
Practice Address - Country:US
Practice Address - Phone:919-383-0171
Practice Address - Fax:919-384-9641
Is Sole Proprietor?:No
Enumeration Date:2011-07-28
Last Update Date:2011-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14267183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist