Provider Demographics
NPI:1447535034
Name:NIKOLICH, SAMUEL S
Entity type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:S
Last Name:NIKOLICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 LYNDON LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-4618
Mailing Address - Country:US
Mailing Address - Phone:502-426-1057
Mailing Address - Fax:502-426-3237
Practice Address - Street 1:520 LYNDON LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-4618
Practice Address - Country:US
Practice Address - Phone:502-426-1057
Practice Address - Fax:502-426-3237
Is Sole Proprietor?:No
Enumeration Date:2011-10-15
Last Update Date:2011-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY8207183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY8207OtherKY PHARMACY LICENSE NUMBER