MEDICARE: ERIC PATRICE SEDE NIETCHO

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	1835P1200X	Pharmacotherapy Pharmacist	20900	NC

General Provider Information

NPI Number	:	1467727560
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIC PATRICE SEDE NIETCHO

Provider Business Mailing Address
First Line	:	4107 ALDERSHOT CT APT C
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-4536
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4107 ALDERSHOT CT APT C
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-4536
Country	:	US
Telephone Number	:	417-619-2821
Fax Number	:

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

Provider Enumeration Date	:	03/21/2012
Last Update Date	:	03/21/2012

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