Provider Demographics
NPI:1851724637
Name:NICHOLAS L SMITH PHARMACY LLC
Entity Type:Organization
Organization Name:NICHOLAS L SMITH PHARMACY LLC
Other - Org Name:SMITH PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER / PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:920-788-8888
Mailing Address - Street 1:1800 FREEDOM RD STE D
Mailing Address - Street 2:
Mailing Address - City:LITTLE CHUTE
Mailing Address - State:WI
Mailing Address - Zip Code:54140-3200
Mailing Address - Country:US
Mailing Address - Phone:920-788-8888
Mailing Address - Fax:920-788-8883
Practice Address - Street 1:1800 FREEDOM RD STE D
Practice Address - Street 2:
Practice Address - City:LITTLE CHUTE
Practice Address - State:WI
Practice Address - Zip Code:54140-3200
Practice Address - Country:US
Practice Address - Phone:920-788-8888
Practice Address - Fax:920-788-8883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-15
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9226-423336C0003X, 3336C0004X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5133905OtherNCPDP
WI1851724637Medicaid
WI9226-42OtherWISCONSIN STATE LICENSE
5133905OtherNCPDP