Healthcare Provider Details

I. General information

NPI: 1306369681
Provider Name (Legal Business Name): CHEYENE JOSEPH NICKERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2017
Last Update Date: 01/17/2025
Certification Date: 01/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

565 JENSEN GROVE DR
BLACKFOOT ID
83221-1682
US

IV. Provider business mailing address

132 E LAKE ST
MCCALL ID
83638-3811
US

V. Phone/Fax

Practice location:
  • Phone: 208-785-0277
  • Fax:
Mailing address:
  • Phone: 208-634-2433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP7793
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: