Provider Demographics
NPI:1588253439
Name:NILES, NICHOLAS MICHAEL (PHARMD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:MICHAEL
Last Name:NILES
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 1:221 SPORTSMANS AVE
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-5635
Mailing Address - Country:US
Mailing Address - Phone:516-582-3359
Mailing Address - Fax:
Practice Address - Street 1:2941 WESTCHESTER AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-4585
Practice Address - Country:US
Practice Address - Phone:718-823-1085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-14
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY067477183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist