Provider Demographics
NPI:1669535274
Name:DOUGLAS E NYKANEN
Entity type:Organization
Organization Name:DOUGLAS E NYKANEN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER AND PHARM
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:NYKANEN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:715-294-2110
Mailing Address - Street 1:PO BOX 279
Mailing Address - Street 2:
Mailing Address - City:OSCEOLA
Mailing Address - State:WI
Mailing Address - Zip Code:54020-0279
Mailing Address - Country:US
Mailing Address - Phone:715-294-2110
Mailing Address - Fax:715-294-1617
Practice Address - Street 1:120 N CASCADE ST
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:WI
Practice Address - Zip Code:54020-7000
Practice Address - Country:US
Practice Address - Phone:715-294-2110
Practice Address - Fax:715-294-1617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI6601-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33048000Medicaid
5117228OtherNCPDP PROVIDER IDENTIFICATION NUMBER
WI33048000Medicaid