Provider Demographics
NPI:1396298626
Name:NDETTI, NICHOLAS NZIOKA JR (PHARM D)
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:NZIOKA
Last Name:NDETTI
Suffix:JR
Gender:M
Credentials:PHARM D
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1919 LATHROP ST
Mailing Address - Street 2:SUITE 109
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-5937
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1919 LATHROP ST
Practice Address - Street 2:SUITE 109
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5937
Practice Address - Country:US
Practice Address - Phone:907-452-1514
Practice Address - Fax:907-452-1917
Is Sole Proprietor?:No
Enumeration Date:2016-08-03
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AK102370183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist