Provider Demographics
NPI:1114290707
Name:NICOLET PHARMACY, INC.
Entity Type:Organization
Organization Name:NICOLET PHARMACY, INC.
Other - Org Name:NICOLET PHARMACY INC-340B PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:DONALDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-276-3646
Mailing Address - Street 1:15481 COMMERCIAL RD
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
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?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-14
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7576423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5133056OtherNCPDP PROVIDER IDENTIFICATION NUMBER