Healthcare Provider Details

I. General information

NPI: 1265722011
Provider Name (Legal Business Name): MAX A NYGAARD R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2011
Last Update Date: 04/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

332 S MAIN ST
MARION OH
43302-5006
US

IV. Provider business mailing address

243 KENTON GALION RD W
MARION OH
43302-9741
US

V. Phone/Fax

Practice location:
  • Phone: 740-382-0650
  • Fax:
Mailing address:
  • Phone: 740-382-0650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03310441
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: