MEDICARE: NELLIS CARE PHARMACY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	PH02838	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2134367	OTHER	PK
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1316212194
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NELLIS CARE PHARMACY INC

Provider Business Mailing Address
First Line	:	316 MOUNT HOPE ST
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89014-7853
Country	:	US
Telephone Number	:	702-531-6523
Fax Number	:	702-531-6524

Provider Business Practice Location Address
First Line	:	348 N NELLIS BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89110-0053
Country	:	US
Telephone Number	:	702-531-6523
Fax Number	:	702-531-6524

Authorized Official
Title or Position	:	MANAGER/OWNER
Name	:	SHAHN SHERAFAT
Credential	:
Telephone Number	:	702-272-2874

Provider Enumeration Date	:	03/13/2012
Last Update Date	:	06/21/2016

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