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General NPI Number Information
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NPI Number | 1053731521
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Entity Type | Individual
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Provider Name | NICHOLAS FETTER
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Gender | Male
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Dates
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Enumeration Date | 04/23/2014
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Last Update Date | 04/23/2014
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Provider Practice Location Address
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Address Line | 3015 TOWER AVE
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City | SUPERIOR
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State | WI
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Zip | 54880-5324
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Country | US
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Telephone | 715-394-5551
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Fax |
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Provider Business Mailing Address
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Address Line | 600 N 23RD AVE E APT 209
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City | DULUTH
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State | MN
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Zip | 55812-1450
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Country | US
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Telephone | 218-310-8652
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 17399-40
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License Number State | WI
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