=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851606982
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLOTTE WILLIS NICHOLS RPH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2010
-----------------------------------------------------
Last Update Date | 08/12/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1011 PERRY HILL RD
-----------------------------------------------------
City | MONTGOMERY
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36109-4521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-270-0660
-----------------------------------------------------
Fax | 334-273-9791
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1330 NORTHINGTON RD
-----------------------------------------------------
City | PRATTVILLE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36067-7019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-361-1719
-----------------------------------------------------
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 | 9977
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------