Provider Demographics
NPI:1740887991
Name:STACHELSKI, NICK
Entity type:Individual
Prefix:
First Name:NICK
Middle Name:
Last Name:STACHELSKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11703 W BRIARWOOD CT
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:IN
Mailing Address - Zip Code:47960-4759
Mailing Address - Country:US
Mailing Address - Phone:574-808-9642
Mailing Address - Fax:
Practice Address - Street 1:3819 SOUTH ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4872
Practice Address - Country:US
Practice Address - Phone:765-446-0575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-01
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26019964A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist