MEDICARE: MARIETTA NICHOLAS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	29619	MD
2	183500000X	Pharmacist	29619	MD

General Provider Information

NPI Number	:	1588427355
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIETTA NICHOLAS

Provider Business Mailing Address
First Line	:	4687 SPRUCE CT UNIT 1
Second Line	:
City	:	JB ANDREWS
State	:	MD
Zip	:	20762-5403
Country	:	US
Telephone Number	:	915-299-3528
Fax Number	:

Provider Business Practice Location Address
First Line	:	7546 ANNAPOLIS RD
Second Line	:
City	:	HYATTSVILLE
State	:	MD
Zip	:	20784-1702
Country	:	US
Telephone Number	:	301-577-6128
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/05/2024
Last Update Date	:	02/05/2024

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Directions to “ MARIETTA NICHOLAS ” Practice Location

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