Provider Demographics
NPI:1275759847
Name:NICOSKI, RANDY T (RPH)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:T
Last Name:NICOSKI
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6194 FAIRFAX CT
Mailing Address - Street 2:
Mailing Address - City:BAXTER
Mailing Address - State:MN
Mailing Address - Zip Code:56425-8733
Mailing Address - Country:US
Mailing Address - Phone:218-829-1986
Mailing Address - Fax:
Practice Address - Street 1:RIVERWOOD HEALTHCARE CENTER
Practice Address - Street 2:200 BUNKER HILL DRIVE
Practice Address - City:AITKIN
Practice Address - State:MN
Practice Address - Zip Code:56431-1865
Practice Address - Country:US
Practice Address - Phone:218-927-5588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2010-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN113321183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist