Provider Demographics
NPI:1124677166
Name:DEITZ, NICKOLAS (PHARMD)
Entity type:Individual
Prefix:DR
First Name:NICKOLAS
Middle Name:
Last Name:DEITZ
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3404 DAVIE RD APT 403
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33314-1629
Mailing Address - Country:US
Mailing Address - Phone:614-581-5957
Mailing Address - Fax:
Practice Address - Street 1:1415 E SUNRISE BLVD
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33304-2324
Practice Address - Country:US
Practice Address - Phone:954-888-8915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-11
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS59778183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist