Provider Demographics
NPI:1548590706
Name:RIECKE, NATHAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:RIECKE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3605 E THOMAS RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-7505
Mailing Address - Country:US
Mailing Address - Phone:602-275-7507
Mailing Address - Fax:602-392-0403
Practice Address - Street 1:3605 E THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-7505
Practice Address - Country:US
Practice Address - Phone:602-275-7507
Practice Address - Fax:602-392-0403
Is Sole Proprietor?:No
Enumeration Date:2010-01-10
Last Update Date:2010-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS016085183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist