Healthcare Provider Details

I. General information

NPI: 1467877316
Provider Name (Legal Business Name): MARK NIEDERKOHR RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2014
Last Update Date: 03/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5858 SPRINGBORO PIKE
DAYTON OH
45449-2809
US

IV. Provider business mailing address

5858 SPRINGBORO PIKE
DAYTON OH
45449-2809
US

V. Phone/Fax

Practice location:
  • Phone: 937-291-8933
  • Fax: 937-291-8965
Mailing address:
  • Phone: 937-291-8933
  • Fax: 937-291-8965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03114775
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: