Healthcare Provider Details

I. General information

NPI: 1457924128
Provider Name (Legal Business Name): NIKISAAGA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2021
Last Update Date: 07/21/2021
Certification Date: 07/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3973 SAINT CHARLES PKWY
WALDORF MD
20602-2683
US

IV. Provider business mailing address

4050 DERRICO PL
WHITE PLAINS MD
20695-2839
US

V. Phone/Fax

Practice location:
  • Phone: 248-495-5705
  • Fax:
Mailing address:
  • Phone: 201-744-0481
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: MANISHKUMAR J PATEL
Title or Position: MANAGER
Credential:
Phone: 248-495-5705