Provider Demographics
NPI:1962078964
Name:MOTT, NATHAN
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:MOTT
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 1:1 CVS DR # 1075
Mailing Address - Street 2:
Mailing Address - City:WOONSOCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02895-6146
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3804 METRO DR
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51501-7732
Practice Address - Country:US
Practice Address - Phone:712-309-3381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-01
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA23878183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist