Provider Demographics
NPI:1467005991
Name:SELBY, NICHOLAS
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:SELBY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6220 SAINT JOE CENTER RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835-2506
Mailing Address - Country:US
Mailing Address - Phone:260-485-7998
Mailing Address - Fax:
Practice Address - Street 1:6220 SAINT JOE CENTER RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46835-2506
Practice Address - Country:US
Practice Address - Phone:260-485-7998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-23
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN260274948183500000X
IL051300874183500000X
IN26027494A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist