Provider Demographics
NPI:1508488529
Name:CLAY, NICOLE (PHARMD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:CLAY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4140 COUNTY ROAD 101 N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55446-2308
Mailing Address - Country:US
Mailing Address - Phone:763-478-4612
Mailing Address - Fax:763-478-4618
Practice Address - Street 1:4140 COUNTY ROAD 101 N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55446-2308
Practice Address - Country:US
Practice Address - Phone:763-478-4612
Practice Address - Fax:763-478-4618
Is Sole Proprietor?:No
Enumeration Date:2020-05-13
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN123432183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist