Healthcare Provider Details

I. General information

NPI: 1083537542
Provider Name (Legal Business Name): NICOLLET PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2805 NICOLLET AVE
MINNEAPOLIS MN
55408-2329
US

IV. Provider business mailing address

2805 NICOLLET AVE
MINNEAPOLIS MN
55408-2329
US

V. Phone/Fax

Practice location:
  • Phone: 612-345-7619
  • Fax:
Mailing address:
  • Phone: 612-345-7619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DEEQ MOHAMMED
Title or Position: RPH-PIC
Credential: PHARM D
Phone: 612-345-7619