Provider Demographics
NPI:1699059840
Name:NIKITIN, STAN (PHARMD)
Entity type:Individual
Prefix:DR
First Name:STAN
Middle Name:
Last Name:NIKITIN
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 1:10944 W ROYAL PALM RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85345-1901
Mailing Address - Country:US
Mailing Address - Phone:847-227-7269
Mailing Address - Fax:
Practice Address - Street 1:10705 W INDIAN SCHOOL RD
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-5636
Practice Address - Country:US
Practice Address - Phone:623-877-3245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS018830183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist