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General NPI Number Information
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NPI Number | 1457460198
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Entity Type | Organization
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Legal Business Name | NICHOLLS PHARMACY
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Dates
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Enumeration Date | 08/29/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1003 VAN STREAT HWY
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City | NICHOLLS
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State | GA
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Zip | 31554
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Country | US
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Telephone | 912-345-2444
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Fax |
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Provider Business Mailing Address
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Address Line | 1003 VAN STREAT HWY PO BOX 247
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City | NICHOLLS
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State | GA
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Zip | 31554
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Country | US
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Telephone | 912-345-2444
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Fax |
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Authorized Official
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Title or Position | OWNER/PHARMACIST
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Name | BRAD W MOBLEY
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Credential | REG PHARMACIST
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Telephone | 912-345-2444
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | PHRE006030
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License Number State | GA
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