Provider Demographics
NPI:1497350698
Name:NICKLE, GARY ALAN (RPH)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:ALAN
Last Name:NICKLE
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 1:150 MADISON RD
Mailing Address - Street 2:
Mailing Address - City:CULPEPER
Mailing Address - State:VA
Mailing Address - Zip Code:22701-3405
Mailing Address - Country:US
Mailing Address - Phone:540-825-8322
Mailing Address - Fax:540-829-8529
Practice Address - Street 1:150 MADISON RD
Practice Address - Street 2:
Practice Address - City:CULPEPER
Practice Address - State:VA
Practice Address - Zip Code:22701-3405
Practice Address - Country:US
Practice Address - Phone:540-825-8322
Practice Address - Fax:540-829-8529
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202009130183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist