Healthcare Provider Details

I. General information

NPI: 1073523932
Provider Name (Legal Business Name): DAVID EUGENE NICKLAS DPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1442 N HARRISON ST
SHAWNEE OK
74801-5208
US

IV. Provider business mailing address

1807 HENSON CT
SHAWNEE OK
74804-4240
US

V. Phone/Fax

Practice location:
  • Phone: 405-273-9906
  • Fax: 405-273-4329
Mailing address:
  • Phone: 405-275-6169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number9416
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: