Healthcare Provider Details

I. General information

NPI: 1578667929
Provider Name (Legal Business Name): MR. WALTER C. NICHOLAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25405 PERDIDO BLVD
ORANGE BEACH AL
36561
US

IV. Provider business mailing address

811 E 24TH AVE
GULF SHORES AL
36542-3113
US

V. Phone/Fax

Practice location:
  • Phone: 251-981-1796
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number7918
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: