Healthcare Provider Details

I. General information

NPI: 1154691764
Provider Name (Legal Business Name): NICOLE CIVIL PHARMACIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2012
Last Update Date: 01/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12807 US HIGHWAY 301
DADE CITY FL
33525-5812
US

IV. Provider business mailing address

10602 LIBERTY BELL DR
TAMPA FL
33647-3656
US

V. Phone/Fax

Practice location:
  • Phone: 352-567-9606
  • Fax:
Mailing address:
  • Phone: 813-476-7943
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS41663
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: