Healthcare Provider Details

I. General information

NPI: 1609319078
Provider Name (Legal Business Name): NICOLAOS KATSIADAKIS JR. PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2016
Last Update Date: 12/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 CHICAGO AVE
MINNEAPOLIS MN
55404-4518
US

IV. Provider business mailing address

2525 CHICAGO AVE
MINNEAPOLIS MN
55404-4518
US

V. Phone/Fax

Practice location:
  • Phone: 612-813-7259
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0200X
TaxonomyPediatric Pharmacist
License Number121305
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: