=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306440672
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICHOLE CONRAD RPH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/26/2020
-----------------------------------------------------
Last Update Date | 11/26/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13098 PUBLISHERS DR
-----------------------------------------------------
City | FISHERS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46038-8826
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-598-4409
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15785 SYMPHONY BLVD
-----------------------------------------------------
City | NOBLESVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46060-4399
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-345-5066
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 26020754A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------