Healthcare Provider Details

I. General information

NPI: 1649873589
Provider Name (Legal Business Name): MR. NICKOLAUS MACDONALD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2020
Last Update Date: 11/20/2020
Certification Date: 11/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040 COLERAIN AVE
CINCINNATI OH
45251-2402
US

IV. Provider business mailing address

9040 COLERAIN AVE
CINCINNATI OH
45251-2402
US

V. Phone/Fax

Practice location:
  • Phone: 513-719-0038
  • Fax:
Mailing address:
  • Phone: 513-719-0038
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number03325882
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03325882
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: