Provider Demographics
NPI:1043577612
Name:PICKENS, NICOLE ALEXANDRIA (PHARMD)
Entity type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:ALEXANDRIA
Last Name:PICKENS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 163
Mailing Address - Street 2:
Mailing Address - City:LORIS
Mailing Address - State:SC
Mailing Address - Zip Code:29569-0163
Mailing Address - Country:US
Mailing Address - Phone:843-504-5170
Mailing Address - Fax:
Practice Address - Street 1:2901 NORTH KINGS HIGHWAY
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577
Practice Address - Country:US
Practice Address - Phone:843-504-5170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-19
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCI-6391183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist