1184646192 NPI number — NIKLAS-MOORE INC

Table of content: (NPI 1184646192)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184646192 NPI number — NIKLAS-MOORE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NIKLAS-MOORE INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
GREEN MOUNTAIN PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184646192
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5700 RT 100 UNIT C-10
Provider Second Line Business Mailing Address:
PO BOX 576
Provider Business Mailing Address City Name:
LONDONDERRY
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05148-0576
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-824-3344
Provider Business Mailing Address Fax Number:
802-824-3332

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5700 RT 100 UNIT C-10
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONDONDERRY
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05148-0576
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-824-3344
Provider Business Practice Location Address Fax Number:
802-824-3332
Provider Enumeration Date:
07/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NIKLAS
Authorized Official First Name:
SARA
Authorized Official Middle Name:
KAY
Authorized Official Title or Position:
OWNER MANAGER
Authorized Official Telephone Number:
802-824-3344

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  0380003348 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1011164 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".




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