Provider Demographics
NPI:1336216860
Name:COSENTINO, NICHOLAS (RPH)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:
Last Name:COSENTINO
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5795 CASSIE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405-4843
Mailing Address - Country:US
Mailing Address - Phone:801-777-0419
Mailing Address - Fax:
Practice Address - Street 1:7321 11TH ST
Practice Address - Street 2:BUILDING 570
Practice Address - City:HILL AFB
Practice Address - State:UT
Practice Address - Zip Code:84056-5012
Practice Address - Country:US
Practice Address - Phone:801-777-0418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6230744-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist