Provider Demographics
NPI:1356944755
Name:LO, NIDA
Entity type:Individual
Prefix:
First Name:NIDA
Middle Name:
Last Name:LO
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 1:3109 LAYLA ST
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32303-7026
Mailing Address - Country:US
Mailing Address - Phone:817-937-8423
Mailing Address - Fax:
Practice Address - Street 1:111 FM 407 E
Practice Address - Street 2:
Practice Address - City:ARGYLE
Practice Address - State:TX
Practice Address - Zip Code:76226-5906
Practice Address - Country:US
Practice Address - Phone:904-240-0838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-18
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS61294183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist