Healthcare Provider Details

I. General information

NPI: 1528516531
Provider Name (Legal Business Name): NICHOLAS CUSHMAN PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2016
Last Update Date: 09/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 VASSAR DR NE
ALBUQUERQUE NM
87106-2725
US

IV. Provider business mailing address

801 VASSAR DR NE
ALBUQUERQUE NM
87106-2725
US

V. Phone/Fax

Practice location:
  • Phone: 505-248-4027
  • Fax: 505-248-7642
Mailing address:
  • Phone: 505-248-4027
  • Fax: 505-248-7642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302041616
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: