Healthcare Provider Details

I. General information

NPI: 1033573258
Provider Name (Legal Business Name): NIS PHARMACY SERVICES, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2016
Last Update Date: 04/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23962 SMILEY RD
NISSWA MN
56468-2386
US

IV. Provider business mailing address

14091 BAXTER DR
BAXTER MN
56425-8699
US

V. Phone/Fax

Practice location:
  • Phone: 218-963-7525
  • Fax: 218-963-4722
Mailing address:
  • Phone: 218-829-3473
  • Fax: 218-454-0353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number264109
License Number StateMN

VIII. Authorized Official

Name: MICHAEL SCHWARTZWALD
Title or Position: PRESIDENT
Credential: RPH
Phone: 218-829-3476