MEDICARE: NIMBLE 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2154599	OTHER		PK

General Provider Information

NPI Number	:	1336510726
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NIMBLE PHARMACY INC

Provider Business Mailing Address
First Line	:	378 CAMBRIDGE AVE
Second Line	:
City	:	PALO ALTO
State	:	CA
Zip	:	94306-1557
Country	:	US
Telephone Number	:	866-966-4625
Fax Number	:

Provider Business Practice Location Address
First Line	:	811 S WESTERN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-4148
Country	:	US
Telephone Number	:	866-966-4625
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TALHA WAQAR
Credential	:
Telephone Number	:	866-966-4625

Provider Enumeration Date	:	10/12/2015
Last Update Date	:	03/29/2016

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