Provider Demographics
NPI:1578680922
Name:BRYCE, NICKALAUS DAVID (PHARMD)
Entity Type:Individual
Prefix:
First Name:NICKALAUS
Middle Name:DAVID
Last Name:BRYCE
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 1:490 W SMITH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT DAVID
Mailing Address - State:AZ
Mailing Address - Zip Code:85630-6133
Mailing Address - Country:US
Mailing Address - Phone:520-720-2629
Mailing Address - Fax:
Practice Address - Street 1:650 N BISBEE AVE
Practice Address - Street 2:
Practice Address - City:WILLCOX
Practice Address - State:AZ
Practice Address - Zip Code:85643-1437
Practice Address - Country:US
Practice Address - Phone:520-384-4612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ15445183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist