Provider Demographics
NPI:1558656942
Name:NILSSON, KIM VINCENT
Entity Type:Individual
Prefix:MR
First Name:KIM
Middle Name:VINCENT
Last Name:NILSSON
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 1:1015 N COURT ST
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-1582
Mailing Address - Country:US
Mailing Address - Phone:330-725-2706
Mailing Address - Fax:330-725-2706
Practice Address - Street 1:1015 N COURT ST
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-1582
Practice Address - Country:US
Practice Address - Phone:330-725-2706
Practice Address - Fax:330-725-2706
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-14
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03211210183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0162443Medicaid
OH340006148OtherMEDCO