Provider Demographics
NPI:1043363484
Name:NUCKOLLS, JAMES KIM (BS)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:KIM
Last Name:NUCKOLLS
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 BARRETT ST
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:TN
Mailing Address - Zip Code:38008-1128
Mailing Address - Country:US
Mailing Address - Phone:731-658-6487
Mailing Address - Fax:
Practice Address - Street 1:600 NUCKOLLS RD
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:TN
Practice Address - Zip Code:38008-1532
Practice Address - Country:US
Practice Address - Phone:731-658-5207
Practice Address - Fax:731-658-1758
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE5645183500000X
TN3703183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist