Healthcare Provider Details

I. General information

NPI: 1629695788
Provider Name (Legal Business Name): JESSICA PAIGE NICHOLS PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2020
Last Update Date: 07/06/2020
Certification Date: 07/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2153 E MAIN ST STE B9
DUNCAN SC
29334-8863
US

IV. Provider business mailing address

1111 BALLENGER RD
INMAN SC
29349-7966
US

V. Phone/Fax

Practice location:
  • Phone: 864-486-4706
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number42514
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: