=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083295687
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIC DOUGLAS NICKEL
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2021
-----------------------------------------------------
Last Update Date | 04/16/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2812 SCIOTO TRL
-----------------------------------------------------
City | PORTSMOUTH
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45662-2244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-355-3568
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 47 DUSTY DR
-----------------------------------------------------
City | MC DERMOTT
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45652-8008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-250-8572
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 03233295
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------