Provider Demographics
NPI:1487243523
Name:MIMMACK, NICHOLAS (PHARMD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:
Last Name:MIMMACK
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:PO BOX 110
Mailing Address - Street 2:
Mailing Address - City:BAYFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:81122-0110
Mailing Address - Country:US
Mailing Address - Phone:970-884-9133
Mailing Address - Fax:970-884-0723
Practice Address - Street 1:871 COUNTY ROAD 501
Practice Address - Street 2:
Practice Address - City:BAYFIELD
Practice Address - State:CO
Practice Address - Zip Code:81122-9462
Practice Address - Country:US
Practice Address - Phone:970-884-9133
Practice Address - Fax:970-884-0723
Is Sole Proprietor?:No
Enumeration Date:2021-01-13
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO21790183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist