Provider Demographics
NPI:1295816692
Name:NICHOLAS, RONALD WAYNE (DPH)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:WAYNE
Last Name:NICHOLAS
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:DR
Other - First Name:RONALD
Other - Middle Name:WAYNE
Other - Last Name:NICHOLAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPH
Mailing Address - Street 1:1106 SE 10TH ST
Mailing Address - Street 2:
Mailing Address - City:WAGONER
Mailing Address - State:OK
Mailing Address - Zip Code:74467-7218
Mailing Address - Country:US
Mailing Address - Phone:918-485-3267
Mailing Address - Fax:
Practice Address - Street 1:326 E CHEROKEE ST
Practice Address - Street 2:
Practice Address - City:WAGONER
Practice Address - State:OK
Practice Address - Zip Code:74467-4706
Practice Address - Country:US
Practice Address - Phone:918-485-2317
Practice Address - Fax:918-485-8483
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7404183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist