MEDICARE: NICHELLE CLEMONS RPH

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	183500000X	Pharmacist	RPHO17206	GA
2	183500000X	Pharmacist	PS29225	FL

General Provider Information

NPI Number	:	1588874002
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHELLE CLEMONS RPH

Provider Business Mailing Address
First Line	:	3354 MOSSWOOD LANE
Second Line	:
City	:	REX
State	:	GA
Zip	:	30273-2169
Country	:	US
Telephone Number	:	770-960-6047
Fax Number	:

Provider Business Practice Location Address
First Line	:	3354 MOSSWOOD LANE
Second Line	:
City	:	REX
State	:	GA
Zip	:	30273-2169
Country	:	US
Telephone Number	:	770-960-6047
Fax Number	:	770-960-1705

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

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	07/08/2007

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