Provider Demographics
NPI:1093709313
Name:NICHOLS, CANDACE MCCULLOUGH (PHARMD)
Entity Type:Individual
Prefix:MRS
First Name:CANDACE
Middle Name:MCCULLOUGH
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 1:1376 BENTEEN PARK DR SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30315-4442
Mailing Address - Country:US
Mailing Address - Phone:770-402-8341
Mailing Address - Fax:
Practice Address - Street 1:1938 PEACHTREE RD NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1267
Practice Address - Country:US
Practice Address - Phone:404-603-1317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH020869183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist