Provider Demographics
NPI:1417450826
Name:BACKHAUS, NICOLE (RPH)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BACKHAUS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:ESTHERVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:51334-2432
Mailing Address - Country:US
Mailing Address - Phone:712-362-5551
Mailing Address - Fax:
Practice Address - Street 1:1221 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ESTHERVILLE
Practice Address - State:IA
Practice Address - Zip Code:51334-2432
Practice Address - Country:US
Practice Address - Phone:712-362-5551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-12
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA19790183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
278781OtherNABP