Provider Demographics
NPI:1720388168
Name:NICKISCH, ERIC J (PHARMD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:J
Last Name:NICKISCH
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 1:20 LAKEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59105-3666
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 CHEYENNE AVE
Practice Address - Street 2:
Practice Address - City:LAME DEER
Practice Address - State:MT
Practice Address - Zip Code:59043-0070
Practice Address - Country:US
Practice Address - Phone:406-477-4444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-02
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT4991183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist