Provider Demographics
NPI:1518459734
Name:NELSON, MARK ALEXANDER
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALEXANDER
Last Name:NELSON
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 1:111 ACKLEN PARK DR APT 117
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1144
Mailing Address - Country:US
Mailing Address - Phone:720-660-5293
Mailing Address - Fax:877-436-3472
Practice Address - Street 1:111 ACKLEN PARK DR APT 117
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-1144
Practice Address - Country:US
Practice Address - Phone:720-660-5293
Practice Address - Fax:877-436-3472
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-04
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN42168183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist