Healthcare Provider Details

I. General information

NPI: 1538503230
Provider Name (Legal Business Name): NICOLE A FLYNN PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2013
Last Update Date: 01/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 W BASELINE RD PHARMACY 3799
MESA AZ
85210-6107
US

IV. Provider business mailing address

240 W BASELINE RD PHARMACY 3799
MESA AZ
85210-6107
US

V. Phone/Fax

Practice location:
  • Phone: 480-668-9512
  • Fax: 480-668-9514
Mailing address:
  • Phone: 480-668-9512
  • Fax: 480-668-9514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberS018922
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPR5105
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: