Provider Demographics
NPI:1699183228
Name:NITZ, MARK
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:NITZ
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 1:2101 SCHOTTHILL WOODS DR
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65101-5520
Mailing Address - Country:US
Mailing Address - Phone:573-659-3700
Mailing Address - Fax:
Practice Address - Street 1:2101 N SCHOTTHILL DR
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65101
Practice Address - Country:US
Practice Address - Phone:573-659-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-28
Last Update Date:2014-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO044848183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist