Provider Demographics
NPI:1669107058
Name:SMITH, NICHOLAS SEAN (CPHT)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:SEAN
Last Name:SMITH
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5185 HOY RD
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-4819
Mailing Address - Country:US
Mailing Address - Phone:307-287-1762
Mailing Address - Fax:
Practice Address - Street 1:5185 HOY RD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-4819
Practice Address - Country:US
Practice Address - Phone:307-287-1762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-19
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYT2886183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician