Healthcare Provider Details

I. General information

NPI: 1972956779
Provider Name (Legal Business Name): MICAH NEVIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2016
Last Update Date: 07/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1131 N 1ST ST
HAMILTON MT
59840-2150
US

IV. Provider business mailing address

1131 N 1ST ST
HAMILTON MT
59840-2150
US

V. Phone/Fax

Practice location:
  • Phone: 406-363-9003
  • Fax:
Mailing address:
  • Phone: 406-363-9003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPHA-PHA-LIC-37905
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: