Healthcare Provider Details

I. General information

NPI: 1700717329
Provider Name (Legal Business Name): HALEY NIKOLAENKO PHARMD
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2026
Last Update Date: 05/25/2026
Certification Date: 05/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 HICKORY ST
MELBOURNE FL
32901-3224
US

IV. Provider business mailing address

635 E NEW HAVEN AVE STE 814
MELBOURNE FL
32901-5550
US

V. Phone/Fax

Practice location:
  • Phone: 321-434-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number1-113268
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2024033784
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS68690
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: