Provider Demographics
NPI:1003487562
Name:SEWELL, NICOLE WILLIS (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:WILLIS
Last Name:SEWELL
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4831 DAMASCUS CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:GRACEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32440-4515
Mailing Address - Country:US
Mailing Address - Phone:850-326-7400
Mailing Address - Fax:
Practice Address - Street 1:4478 MARKET ST
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-3441
Practice Address - Country:US
Practice Address - Phone:850-526-1800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS62560183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist