Provider Demographics
NPI:1962003012
Name:HENNECKE, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:HENNECKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1495 E STATE ROAD 48
Mailing Address - Street 2:
Mailing Address - City:SHELBURN
Mailing Address - State:IN
Mailing Address - Zip Code:47879-8151
Mailing Address - Country:US
Mailing Address - Phone:812-249-8667
Mailing Address - Fax:
Practice Address - Street 1:2150 E NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:BRAZIL
Practice Address - State:IN
Practice Address - Zip Code:47834-2831
Practice Address - Country:US
Practice Address - Phone:812-443-0466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26027755A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist