Provider Demographics
NPI:1346360252
Name:NICHOLS, KIMBERLY MCCLURE I (BS)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:MCCLURE
Last Name:NICHOLS
Suffix:I
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 DAVIS ST
Mailing Address - Street 2:
Mailing Address - City:NEPTUNE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32266-4928
Mailing Address - Country:US
Mailing Address - Phone:904-241-8239
Mailing Address - Fax:
Practice Address - Street 1:290 SOLANA RD
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-2234
Practice Address - Country:US
Practice Address - Phone:904-543-8678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL16197183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCPH0018892OtherPHARMACY LICENSE
DCPH0018892OtherPHARMACY LICENSE