Provider Demographics
NPI:1073161063
Name:NICHOLS, EKATERINA
Entity Type:Individual
Prefix:
First Name:EKATERINA
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:238 S US HIGHWAY 17
Mailing Address - Street 2:
Mailing Address - City:EAST PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32131-6059
Mailing Address - Country:US
Mailing Address - Phone:386-328-6713
Mailing Address - Fax:
Practice Address - Street 1:238 S US HIGHWAY 17
Practice Address - Street 2:
Practice Address - City:EAST PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32131-6059
Practice Address - Country:US
Practice Address - Phone:386-328-6713
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-03
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS59919183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist