Healthcare Provider Details

I. General information

NPI: 1750680997
Provider Name (Legal Business Name): CARRIE G NICHOLS RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2011
Last Update Date: 03/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

932 CROSS LANES DR
CROSS LANES WV
25313-1315
US

IV. Provider business mailing address

932 CROSS LANES DR
CROSS LANES WV
25313-1315
US

V. Phone/Fax

Practice location:
  • Phone: 304-776-0405
  • Fax: 304-776-2108
Mailing address:
  • Phone: 304-776-0405
  • Fax: 304-776-2108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP006416
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: