Provider Demographics
NPI:1316480270
Name:NOLA, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:NOLA
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 1:719 W 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:KS
Mailing Address - Zip Code:67010-1314
Mailing Address - Country:US
Mailing Address - Phone:316-775-1168
Mailing Address - Fax:
Practice Address - Street 1:719 W 7TH AVE
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:KS
Practice Address - Zip Code:67010-1314
Practice Address - Country:US
Practice Address - Phone:316-775-1168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-28
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-100068183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist