Healthcare Provider Details

I. General information

NPI: 1104601186
Provider Name (Legal Business Name): NICOLE ANNE MAGSAMBOL APA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2023
Last Update Date: 08/29/2023
Certification Date: 08/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1808 ALBANY ST
BEECH GROVE IN
46107-1404
US

IV. Provider business mailing address

1808 ALBANY ST
BEECH GROVE IN
46107-1404
US

V. Phone/Fax

Practice location:
  • Phone: 317-786-1031
  • Fax:
Mailing address:
  • Phone: 317-786-1031
  • Fax: 317-786-1036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26030481A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: