Provider Demographics
NPI:1336438787
Name:NEELY, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:NEELY
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:G4007 S SAGINAW ST
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48529-1617
Mailing Address - Country:US
Mailing Address - Phone:810-742-7002
Mailing Address - Fax:
Practice Address - Street 1:G4007 S SAGINAW ST
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48529-1617
Practice Address - Country:US
Practice Address - Phone:810-742-7002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-06
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302028472183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist