Healthcare Provider Details

I. General information

NPI: 1669070652
Provider Name (Legal Business Name): NICKOLAS WILLIAM SCOTT PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2020
Last Update Date: 10/13/2020
Certification Date: 10/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4369 BALL ROAD NE
BLAINE MN
55014
US

IV. Provider business mailing address

1435 HAMPSHIRE AVE S APT 108
ST LOUIS PARK MN
55426-2164
US

V. Phone/Fax

Practice location:
  • Phone: 763-784-0862
  • Fax:
Mailing address:
  • Phone: 563-529-2088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number124841
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: