Provider Demographics
NPI:1316147127
Name:THOMAS, NICK
Entity type:Individual
Prefix:
First Name:NICK
Middle Name:
Last Name:THOMAS
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 1:310 SHADY LN
Mailing Address - Street 2:
Mailing Address - City:MANDAN
Mailing Address - State:ND
Mailing Address - Zip Code:58554-3828
Mailing Address - Country:US
Mailing Address - Phone:701-663-7049
Mailing Address - Fax:
Practice Address - Street 1:10 NORTH RIVER RD
Practice Address - Street 2:
Practice Address - City:FT YATES
Practice Address - State:ND
Practice Address - Zip Code:58538
Practice Address - Country:US
Practice Address - Phone:701-854-3831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-19
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5127183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist