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General NPI Number Information
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NPI Number | 1568755478
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Entity Type | Individual
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Provider Name | NIKKI BROADNEAUX PHARMD
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Gender | Female
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Dates
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Enumeration Date | 05/25/2011
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Last Update Date | 05/25/2011
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Provider Practice Location Address
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Address Line | 477 TALLWOOD DR
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City | STONE MOUNTAIN
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State | GA
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Zip | 30083-4461
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Country | US
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Telephone | 414-418-0530
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 180
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City | PINE LAKE
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State | GA
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Zip | 30072-0180
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Country | US
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Telephone | 414-418-0530
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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 | 021146
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | PS 32935
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 12969-40
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License Number State | WI
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