Healthcare Provider Details

I. General information

NPI: 1780178640
Provider Name (Legal Business Name): NICHOLAS ANDREW GILLESPIE PHARMD.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2018
Last Update Date: 06/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 S OATES ST
DOTHAN AL
36301-5694
US

IV. Provider business mailing address

125 MOUNTAINVIEW DR
MONTGOMERY AL
36109-4107
US

V. Phone/Fax

Practice location:
  • Phone: 334-702-0840
  • Fax: 334-702-0580
Mailing address:
  • Phone: 334-221-9193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number19947
License Number StateAL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier19947
Identifier TypeOTHER
Identifier StateAL
Identifier IssuerALABAMA STATE BOARD OF PHARMACY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: