Provider Demographics
NPI:1184748808
Name:NICHOLLS PHARMACY LLC
Entity type:Organization
Organization Name:NICHOLLS PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER,PRES,PIC,AO
Authorized Official - Prefix:
Authorized Official - First Name:JAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:912-345-1021
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:NICHOLLS
Mailing Address - State:GA
Mailing Address - Zip Code:31554-0247
Mailing Address - Country:US
Mailing Address - Phone:912-345-1021
Mailing Address - Fax:912-345-1023
Practice Address - Street 1:1003 VAN STREAT HWY
Practice Address - Street 2:
Practice Address - City:NICHOLLS
Practice Address - State:GA
Practice Address - Zip Code:31554-5031
Practice Address - Country:US
Practice Address - Phone:912-345-1021
Practice Address - Fax:912-345-1023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
GAPHRE0091343336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA569772164AMedicaid
2016489OtherPK