Provider Demographics
NPI:1063248821
Name:NEIDHARDT, DAKOTA
Entity type:Individual
Prefix:
First Name:DAKOTA
Middle Name:
Last Name:NEIDHARDT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16415 E PALISADES BLVD
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN HILLS
Mailing Address - State:AZ
Mailing Address - Zip Code:85268-3763
Mailing Address - Country:US
Mailing Address - Phone:480-837-6748
Mailing Address - Fax:480-837-6752
Practice Address - Street 1:16415 E PALISADES BLVD
Practice Address - Street 2:
Practice Address - City:FOUNTAIN HILLS
Practice Address - State:AZ
Practice Address - Zip Code:85268-3763
Practice Address - Country:US
Practice Address - Phone:480-837-6748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS027184183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist