Provider Demographics
NPI:1962410431
Name:ERIK L NELSON
Entity type:Organization
Organization Name:ERIK L NELSON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIK
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:269-665-9727
Mailing Address - Street 1:PO BOX 87
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49083-0087
Mailing Address - Country:US
Mailing Address - Phone:269-665-9727
Mailing Address - Fax:269-665-9575
Practice Address - Street 1:10310 MILLER DR
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:MI
Practice Address - Zip Code:49053-9581
Practice Address - Country:US
Practice Address - Phone:269-665-9727
Practice Address - Fax:269-665-9575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53150081623336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2042869OtherPK
MI1962410431Medicaid
MI2328638Medicaid