1396298626 NPI number — MR. NICHOLAS NZIOKA NDETTI JR. PHARM D.

Table of content: MR. NICHOLAS NZIOKA NDETTI JR. PHARM D. (NPI 1396298626)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396298626 NPI number — MR. NICHOLAS NZIOKA NDETTI JR. PHARM D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NDETTI
Provider First Name:
NICHOLAS
Provider Middle Name:
NZIOKA
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
PHARM D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1396298626
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/23/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1919 LATHROP ST
Provider Second Line Business Mailing Address:
SUITE 109
Provider Business Mailing Address City Name:
FAIRBANKS
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99701-5937
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1919 LATHROP ST
Provider Second Line Business Practice Location Address:
SUITE 109
Provider Business Practice Location Address City Name:
FAIRBANKS
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99701-5937
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-452-1514
Provider Business Practice Location Address Fax Number:
907-452-1917
Provider Enumeration Date:
08/03/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  102370 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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