MEDICARE: MR. CHARLES D NICHOLS RPH

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	PS0019225	FL

General Provider Information

NPI Number	:	1497858492
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHARLES D NICHOLS RPH

Provider Business Mailing Address
First Line	:	227 DAVIS ST
Second Line	:
City	:	NEPTUNE BEACH
State	:	FL
Zip	:	32266-4928
Country	:	US
Telephone Number	:	904-241-8239
Fax Number	:

Provider Business Practice Location Address
First Line	:	1209 ATLANTIC BLVD
Second Line	:
City	:	NEPTUNE BEACH
State	:	FL
Zip	:	32266-1711
Country	:	US
Telephone Number	:	904-249-3900
Fax Number	:	904-249-9009

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

Provider Enumeration Date	:	09/06/2006
Last Update Date	:	07/08/2007

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