MEDICARE: NICHOLAS SELBY

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	183500000X	Pharmacist	260274948	IN
2	183500000X	Pharmacist	051300874	IL
3	183500000X	Pharmacist	26027494A	IN

General Provider Information

NPI Number	:	1467005991
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLAS SELBY

Provider Business Mailing Address
First Line	:	6220 SAINT JOE CENTER RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46835-2506
Country	:	US
Telephone Number	:	260-485-7998
Fax Number	:

Provider Business Practice Location Address
First Line	:	6220 SAINT JOE CENTER RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46835-2506
Country	:	US
Telephone Number	:	260-485-7998
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/23/2019
Last Update Date	:	08/22/2019

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Directions to “ NICHOLAS SELBY ” Practice Location

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