Provider Demographics
NPI:1952986200
Name:MAYNE, NICOLE CORINA (PHARMD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:CORINA
Last Name:MAYNE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1541 POWERS BLVD
Mailing Address - Street 2:
Mailing Address - City:BELGRADE
Mailing Address - State:MT
Mailing Address - Zip Code:59714-7723
Mailing Address - Country:US
Mailing Address - Phone:303-921-9545
Mailing Address - Fax:
Practice Address - Street 1:931 HIGHLAND BLVD STE 3130
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-6914
Practice Address - Country:US
Practice Address - Phone:303-921-9545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-17
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPHA-PHA-LIC-629593336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy