Provider Demographics
NPI:1295108967
Name:STACK, NICHOLAS (BS IN PHARMACY)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:STACK
Suffix:
Gender:M
Credentials:BS IN PHARMACY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1618 S 115TH CT APT 211
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53214-3785
Mailing Address - Country:US
Mailing Address - Phone:414-774-6790
Mailing Address - Fax:
Practice Address - Street 1:5851 S PACKARD AVE
Practice Address - Street 2:
Practice Address - City:CUDAHY
Practice Address - State:WI
Practice Address - Zip Code:53110-2615
Practice Address - Country:US
Practice Address - Phone:414-744-6058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-03
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10632-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI10632-40OtherPHARMACIST LICENSE