Healthcare Provider Details

I. General information

NPI: 1487945580
Provider Name (Legal Business Name): MARLENE KAY NICHOLS RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2011
Last Update Date: 04/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 W. MITCHELL ST
PETOSKEY MI
49770
US

IV. Provider business mailing address

4560 BRUBAKER RD
PETOSKEY MI
49770-9556
US

V. Phone/Fax

Practice location:
  • Phone: 231-347-8282
  • Fax: 231-347-4046
Mailing address:
  • Phone: 231-348-3356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302022938
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: