Healthcare Provider Details

I. General information

NPI: 1740883669
Provider Name (Legal Business Name): NICHOLAS DONNELLY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2020
Last Update Date: 07/19/2025
Certification Date: 07/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MAR WALT DR
FORT WALTON BEACH FL
32547-6708
US

IV. Provider business mailing address

1000 MAR WALT DR
FORT WALTON BEACH FL
32547-6708
US

V. Phone/Fax

Practice location:
  • Phone: 850-862-1111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS58006
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: