Provider Demographics
NPI:1083295687
Name:NICKEL, ERIC DOUGLAS
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:DOUGLAS
Last Name:NICKEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 DUSTY DR
Mailing Address - Street 2:
Mailing Address - City:MC DERMOTT
Mailing Address - State:OH
Mailing Address - Zip Code:45652-8008
Mailing Address - Country:US
Mailing Address - Phone:740-250-8572
Mailing Address - Fax:
Practice Address - Street 1:2812 SCIOTO TRL
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-2244
Practice Address - Country:US
Practice Address - Phone:740-355-3568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-16
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03233295183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist