MEDICARE: NATHEN DALE CONNOLLY PHARMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	18540	NV

General Provider Information

NPI Number	:	1306278239
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NATHEN DALE CONNOLLY PHARMD

Provider Business Mailing Address
First Line	:	5509 DALLE VALLEY ST
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-7846
Country	:	US
Telephone Number	:	702-374-4116
Fax Number	:

Provider Business Practice Location Address
First Line	:	2975 E SAHARA AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-4114
Country	:	US
Telephone Number	:	702-457-8325
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/01/2013
Last Update Date	:	09/30/2015

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