=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790800902
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICHOLAS FORD PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3107-15 BOULEVARD
-----------------------------------------------------
City | COLONIAL HEIGHTS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-520-4106
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 724 SYCAMORE SPRINGS DRIVE
-----------------------------------------------------
City | CHESTER
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23836
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-266-8949
-----------------------------------------------------
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 | 0202207488
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------