Healthcare Provider Details

I. General information

NPI: 1417686189
Provider Name (Legal Business Name): JESSICA NICHOLS MAIN PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA ROSE NICHOLS PHARMD

II. Dates (important events)

Enumeration Date: 06/08/2022
Last Update Date: 06/08/2022
Certification Date: 06/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

785 N MEDICAL CENTER DR W
CLOVIS CA
93611-6878
US

IV. Provider business mailing address

2631 E ECLIPSE AVE
FRESNO CA
93720-4625
US

V. Phone/Fax

Practice location:
  • Phone: 559-387-1862
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number81345
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: