Provider Demographics
NPI:1689856957
Name:NAKHLA, NARDINE (RPH)
Entity Type:Individual
Prefix:MISS
First Name:NARDINE
Middle Name:
Last Name:NAKHLA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 NELSON ST UNIT 2215
Mailing Address - Street 2:
Mailing Address - City:CAZENOVIA
Mailing Address - State:NY
Mailing Address - Zip Code:13035-1322
Mailing Address - Country:US
Mailing Address - Phone:315-682-0767
Mailing Address - Fax:315-655-2152
Practice Address - Street 1:95 NELSON ST
Practice Address - Street 2:
Practice Address - City:CAZENOVIA
Practice Address - State:NY
Practice Address - Zip Code:13035-1322
Practice Address - Country:US
Practice Address - Phone:315-655-4450
Practice Address - Fax:315-655-2152
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-28
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY20051723183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01083710Medicaid