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General NPI Number Information
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NPI Number | 1134958192
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Entity Type | Individual
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Provider Name | NICKLAS A SIMPSON
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Gender | Male
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Dates
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Enumeration Date | 07/29/2024
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Last Update Date | 07/29/2024
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Provider Practice Location Address
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Address Line | 10700 W USTICK RD
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City | BOISE
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State | ID
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Zip | 83713-5103
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Country | US
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Telephone | 208-322-7788
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Fax |
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Provider Business Mailing Address
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Address Line | 14431 W SEDONA DR
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City | BOISE
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State | ID
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Zip | 83713-0964
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Country | US
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Telephone |
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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 | I75812
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License Number State | ID
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