Provider Demographics
NPI:1225598501
Name:NICHOLS, CLARENCE DEWEY
Entity Type:Individual
Prefix:
First Name:CLARENCE
Middle Name:DEWEY
Last Name:NICHOLS
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:PO BOX 1755
Mailing Address - Street 2:
Mailing Address - City:CORSICANA
Mailing Address - State:TX
Mailing Address - Zip Code:75151-1755
Mailing Address - Country:US
Mailing Address - Phone:903-875-4955
Mailing Address - Fax:903-874-2108
Practice Address - Street 1:225 SW COUNTY ROAD 0020
Practice Address - Street 2:
Practice Address - City:CORSICANA
Practice Address - State:TX
Practice Address - Zip Code:75110-9313
Practice Address - Country:US
Practice Address - Phone:903-875-4955
Practice Address - Fax:903-874-2108
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-22
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX27013183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX27013OtherPHARMACY BOARD