Provider Demographics
NPI:1043525090
Name:WITUCKI, NICHOLAS MATTHEW (PHARM D)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:MATTHEW
Last Name:WITUCKI
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 STAG RUN CIR
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35226-2337
Mailing Address - Country:US
Mailing Address - Phone:610-554-7916
Mailing Address - Fax:
Practice Address - Street 1:3107 LURLEEN B WALLACE BLVD
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:AL
Practice Address - Zip Code:35476-3256
Practice Address - Country:US
Practice Address - Phone:205-333-9343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-15
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL16680183500000X
PARP443675183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist