Provider Demographics
NPI:1861820110
Name:IKNER, NATHAN LEE
Entity Type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:LEE
Last Name:IKNER
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:NATHAN
Other - Middle Name:LEE
Other - Last Name:IKNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BSPHARRM
Mailing Address - Street 1:4390 COLWICK RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-2310
Mailing Address - Country:US
Mailing Address - Phone:704-364-3444
Mailing Address - Fax:704-364-1320
Practice Address - Street 1:4390 COLWICK RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-2310
Practice Address - Country:US
Practice Address - Phone:704-364-3444
Practice Address - Fax:704-364-1320
Is Sole Proprietor?:No
Enumeration Date:2013-10-24
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11368183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist