Healthcare Provider Details

I. General information

NPI: 1275122962
Provider Name (Legal Business Name): NICOLAS CONTRERAS RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2021
Last Update Date: 01/16/2021
Certification Date: 01/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1141 STATE ROAD 20
INTERLACHEN FL
32148-5406
US

IV. Provider business mailing address

1141 STATE ROAD 20
INTERLACHEN FL
32148-5406
US

V. Phone/Fax

Practice location:
  • Phone: 386-684-4991
  • Fax:
Mailing address:
  • Phone: 386-684-4991
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS40721
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: