Provider Demographics
NPI:1285017921
Name:NICODEMUS, RACHEL
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:
Last Name:NICODEMUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 WASHINGTON DR
Mailing Address - Street 2:
Mailing Address - City:MONESSEN
Mailing Address - State:PA
Mailing Address - Zip Code:15062-2321
Mailing Address - Country:US
Mailing Address - Phone:724-562-7083
Mailing Address - Fax:
Practice Address - Street 1:5 WASHINGTON DR
Practice Address - Street 2:
Practice Address - City:MONESSEN
Practice Address - State:PA
Practice Address - Zip Code:15062-2321
Practice Address - Country:US
Practice Address - Phone:724-562-7083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-30
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP449219183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist