Healthcare Provider Details

I. General information

NPI: 1104435528
Provider Name (Legal Business Name): CASEY NICHOLS PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2020
Last Update Date: 07/31/2020
Certification Date: 07/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 14TH ST W STE 150
WILLISTON ND
58801-4080
US

IV. Provider business mailing address

4915 11TH AVE W APT 405
WILLISTON ND
58801-5365
US

V. Phone/Fax

Practice location:
  • Phone: 701-572-7979
  • Fax: 701-572-7981
Mailing address:
  • Phone: 406-498-6927
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPHA-PHA-LIC-62960
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH6178
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: