Healthcare Provider Details

I. General information

NPI: 1669535274
Provider Name (Legal Business Name): DOUGLAS E NYKANEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 05/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 N CASCADE ST
OSCEOLA WI
54020-7000
US

IV. Provider business mailing address

PO BOX 279
OSCEOLA WI
54020-0279
US

V. Phone/Fax

Practice location:
  • Phone: 715-294-2110
  • Fax: 715-294-1617
Mailing address:
  • Phone: 715-294-2110
  • Fax: 715-294-1617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number6601-42
License Number StateWI

VIII. Authorized Official

Name: DOUGLAS NYKANEN
Title or Position: OWNER AND PHARM
Credential: RPH
Phone: 715-294-2110