Provider Demographics
NPI:1932784212
Name:DAVE, NIMISA
Entity Type:Individual
Prefix:
First Name:NIMISA
Middle Name:
Last Name:DAVE
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 1:340 BLACKWELL BND
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30004-1200
Mailing Address - Country:US
Mailing Address - Phone:630-453-2278
Mailing Address - Fax:
Practice Address - Street 1:340 BLACKWELL BND
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30004-1200
Practice Address - Country:US
Practice Address - Phone:630-453-2278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-17
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051040156183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist