Provider Demographics
NPI:1184646192
Name:NIKLAS-MOORE INC
Entity Type:Organization
Organization Name:NIKLAS-MOORE INC
Other - Org Name:GREEN MOUNTAIN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:NIKLAS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD RPH
Authorized Official - Phone:802-824-3344
Mailing Address - Street 1:5700 RT 100 UNIT C-10
Mailing Address - Street 2:PO BOX 576
Mailing Address - City:LONDONDERRY
Mailing Address - State:VT
Mailing Address - Zip Code:05148-0576
Mailing Address - Country:US
Mailing Address - Phone:802-824-3344
Mailing Address - Fax:802-824-3332
Practice Address - Street 1:5700 RT 100 UNIT C-10
Practice Address - Street 2:
Practice Address - City:LONDONDERRY
Practice Address - State:VT
Practice Address - Zip Code:05148-0576
Practice Address - Country:US
Practice Address - Phone:802-824-3344
Practice Address - Fax:802-824-3332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0380003348183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1011164Medicaid
5366680001Medicare ID - Type Unspecified