Provider Demographics
NPI:1407450778
Name:MILLER, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MILLER
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 1:2137 N YOUNG BLVD
Mailing Address - Street 2:
Mailing Address - City:CHIEFLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32626-1955
Mailing Address - Country:US
Mailing Address - Phone:352-493-2592
Mailing Address - Fax:352-493-9353
Practice Address - Street 1:2137 N YOUNG BLVD
Practice Address - Street 2:
Practice Address - City:CHIEFLAND
Practice Address - State:FL
Practice Address - Zip Code:32626-1955
Practice Address - Country:US
Practice Address - Phone:352-493-2592
Practice Address - Fax:352-493-9353
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-26
Last Update Date:2020-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS43919183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS43919OtherPHARMACY LICENSE NUMBER