MEDICARE: NICOLE NEUKUM

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	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	19726	MD
2	183500000X	Pharmacist	19726	MD

General Provider Information

NPI Number	:	1861951345
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE NEUKUM

Provider Business Mailing Address
First Line	:	14330 JARRETTSVILLE PIKE
Second Line	:
City	:	PHOENIX
State	:	MD
Zip	:	21131-1743
Country	:	US
Telephone Number	:	410-666-1700
Fax Number	:	410-666-7140

Provider Business Practice Location Address
First Line	:	14330 JARRETTSVILLE PIKE
Second Line	:
City	:	PHOENIX
State	:	MD
Zip	:	21131-1743
Country	:	US
Telephone Number	:	410-666-1700
Fax Number	:	410-666-7140

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

Provider Enumeration Date	:	03/14/2019
Last Update Date	:	07/07/2019

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Directions to “ NICOLE NEUKUM ” Practice Location

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