MEDICARE: KATHY REBECCA NICHOLS

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	RP0004938	WV

General Provider Information

NPI Number	:	1669957148
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHY REBECCA NICHOLS

Provider Business Mailing Address
First Line	:	149 IVY LN
Second Line	:
City	:	PARSONS
State	:	WV
Zip	:	26287-1337
Country	:	US
Telephone Number	:	304-478-2319
Fax Number	:

Provider Business Practice Location Address
First Line	:	149 IVY LN
Second Line	:
City	:	PARSONS
State	:	WV
Zip	:	26287-1337
Country	:	US
Telephone Number	:	304-478-2319
Fax Number	:	304-478-2532

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

Provider Enumeration Date	:	10/01/2018
Last Update Date	:	10/01/2018

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