Provider Demographics
NPI:1598804940
Name:NYDLE, MICHAEL EDWARD (RPH)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:EDWARD
Last Name:NYDLE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 MENAUL BLVD NE
Mailing Address - Street 2:UNIT 2402
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-1531
Mailing Address - Country:US
Mailing Address - Phone:505-821-4577
Mailing Address - Fax:
Practice Address - Street 1:201 CEDAR ST SE STE 201
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4917
Practice Address - Country:US
Practice Address - Phone:505-841-1490
Practice Address - Fax:505-841-1708
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00005961183500000X
IA14506183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARP043450ROtherPHARMACY LICENSE
IL051-036410OtherPHARMACY LICENSE
IA14506OtherPHARMACY LICENSE
MN116470-9OtherPHARMACY LICENSE
NMRP00005961OtherPHARMACY LICENSE