Healthcare Provider Details

I. General information

NPI: 1952986200
Provider Name (Legal Business Name): NICOLE CORINA MAYNE PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2021
Last Update Date: 03/17/2021
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

931 HIGHLAND BLVD STE 3130
BOZEMAN MT
59715-6914
US

IV. Provider business mailing address

1541 POWERS BLVD
BELGRADE MT
59714-7723
US

V. Phone/Fax

Practice location:
  • Phone: 303-921-9545
  • Fax:
Mailing address:
  • Phone: 303-921-9545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License NumberPHA-PHA-LIC-62959
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: