Provider Demographics
NPI:1417292558
Name:NICHOLS, BRYAN L (RPH)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:L
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2235 S 1300 W
Mailing Address - Street 2:SUITE D
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-7241
Mailing Address - Country:US
Mailing Address - Phone:801-302-8555
Mailing Address - Fax:801-302-8600
Practice Address - Street 1:2235 S 1300 W
Practice Address - Street 2:SUITE D
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84119-7241
Practice Address - Country:US
Practice Address - Phone:801-302-8555
Practice Address - Fax:801-302-8600
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-29
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1508381701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist