Provider Demographics
NPI:1073681458
Name:NICHOLS, LARA ANN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:LARA
Middle Name:ANN
Last Name:NICHOLS
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 1:5180 PINYON DR
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-5020
Mailing Address - Country:US
Mailing Address - Phone:208-478-1196
Mailing Address - Fax:
Practice Address - Street 1:990 S 8TH ST
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83209-0001
Practice Address - Country:US
Practice Address - Phone:208-282-3407
Practice Address - Fax:208-282-6150
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5794183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist