Provider Demographics
NPI:1679888614
Name:NICKELSON, GENA LAGRANGE (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:GENA
Middle Name:LAGRANGE
Last Name:NICKELSON
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1544 MANHATTAN BLVD
Mailing Address - Street 2:
Mailing Address - City:HARVEY
Mailing Address - State:LA
Mailing Address - Zip Code:70058-3406
Mailing Address - Country:US
Mailing Address - Phone:504-362-7780
Mailing Address - Fax:504-368-9351
Practice Address - Street 1:1544 MANHATTAN BLVD
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:LA
Practice Address - Zip Code:70058-3406
Practice Address - Country:US
Practice Address - Phone:504-362-7780
Practice Address - Fax:504-368-9351
Is Sole Proprietor?:No
Enumeration Date:2010-08-14
Last Update Date:2010-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA17281183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist