Provider Demographics
NPI:1952407082
Name:NELSON, CLYDE JOSEPH
Entity Type:Individual
Prefix:MR
First Name:CLYDE
Middle Name:JOSEPH
Last Name:NELSON
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:CLYDE
Other - Middle Name:JOSEPH
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHARMACIST
Mailing Address - Street 1:7203 DONNA DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-1733
Mailing Address - Country:US
Mailing Address - Phone:608-836-8263
Mailing Address - Fax:
Practice Address - Street 1:2500 OVERLOOK TER
Practice Address - Street 2:PHARMACY DEPT
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-2254
Practice Address - Country:US
Practice Address - Phone:608-256-1901
Practice Address - Fax:608-280-7279
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7203183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI7203OtherPHARMACY LICENSE