Provider Demographics
NPI:1316212194
Name:NELLIS CARE PHARMACY INC
Entity type:Organization
Organization Name:NELLIS CARE PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHERAFAT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-272-2874
Mailing Address - Street 1:316 MOUNT HOPE ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89014-7853
Mailing Address - Country:US
Mailing Address - Phone:702-531-6523
Mailing Address - Fax:702-531-6524
Practice Address - Street 1:348 N NELLIS BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89110-0053
Practice Address - Country:US
Practice Address - Phone:702-531-6523
Practice Address - Fax:702-531-6524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-13
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NVPH028383336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV10052733Medicaid
2134367OtherPK
NV1316212194Medicaid