Organization
NICOLET PHARMACY, INC.
Active
Other names
Nicolet Pharmacy Inc-340B Pharmacy
Organization subpart
No
Provider details
NPI number
Authorized official
GARY DONALDSON (PRESIDENT)
(715) 276-3646
Entity
Organization
Contact information
Practice address
15481 COMMERCIAL RD, LAKEWOOD, WI 54138-9677
(715) 276-3646
(715) 276-9568
Mailing address
15481 COMMERCIAL RD, LAKEWOOD, WI 54138-9677
(715) 276-3646
(715) 276-9568
Taxonomy
Speciality
Code
Description
License number
State
3336C0003X
Community/Retail Pharmacy
Primary
757642
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
5133056
NCPDP PROVIDER IDENTIFICATION NUMBER
—
Enumeration date
02/14/2012
Last updated
02/14/2012
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