Provider Demographics
NPI:1124435417
Name:NICOLAUS, ROGER
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:NICOLAUS
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 1:1000 ROBERT RD
Mailing Address - Street 2:
Mailing Address - City:GRANTS
Mailing Address - State:NM
Mailing Address - Zip Code:87020-4012
Mailing Address - Country:US
Mailing Address - Phone:505-285-3378
Mailing Address - Fax:505-285-3760
Practice Address - Street 1:1000 ROBERT RD
Practice Address - Street 2:
Practice Address - City:GRANTS
Practice Address - State:NM
Practice Address - Zip Code:87020-4012
Practice Address - Country:US
Practice Address - Phone:505-285-3378
Practice Address - Fax:505-285-3760
Is Sole Proprietor?:No
Enumeration Date:2014-07-17
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00007208183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist