MEDICARE: ALEXIS ROSE NICOSON PHARMD

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	183500000X	Pharmacist	03445807	OH

General Provider Information

NPI Number	:	1366326852
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALEXIS ROSE NICOSON PHARMD

Provider Business Mailing Address
First Line	:	804 MEADOWOOD BLVD
Second Line	:
City	:	MADISON
State	:	OH
Zip	:	44057-2914
Country	:	US
Telephone Number	:	440-321-9956
Fax Number	:

Provider Business Practice Location Address
First Line	:	7301 LAKE SHORE BLVD
Second Line	:
City	:	MENTOR
State	:	OH
Zip	:	44060-3029
Country	:	US
Telephone Number	:	440-602-6071
Fax Number	:

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

Provider Enumeration Date	:	08/05/2025
Last Update Date	:	08/05/2025

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