Provider Demographics
NPI:1164449070
Name:NICHOLS DRUG STORES INC
Entity Type:Organization
Organization Name:NICHOLS DRUG STORES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:LEO
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-757-3749
Mailing Address - Street 1:112 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49454-1221
Mailing Address - Country:US
Mailing Address - Phone:231-757-3749
Mailing Address - Fax:231-757-2396
Practice Address - Street 1:112 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SCOTTVILLE
Practice Address - State:MI
Practice Address - Zip Code:49454-1221
Practice Address - Country:US
Practice Address - Phone:231-757-3749
Practice Address - Fax:231-757-2396
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010016143336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1518947Medicaid
MI1986223Medicaid
MI1986223Medicaid
MI0735890001Medicare ID - Type Unspecified