Provider Demographics
NPI:1487088431
Name:SLACK, ERIN DIANE
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:DIANE
Last Name:SLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:DIANE
Other - Last Name:WALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:965 MCKINLEY VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89012-5308
Mailing Address - Country:US
Mailing Address - Phone:602-295-8900
Mailing Address - Fax:
Practice Address - Street 1:965 MCKINLEY VIEW AVE
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89012-5308
Practice Address - Country:US
Practice Address - Phone:602-295-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-27
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS020095183500000X
NV18773183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist