Provider Demographics
NPI:1609217959
Name:NICOLA, JACQUELINE NICOLE (PHARMD)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:NICOLE
Last Name:NICOLA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:MISS
Other - First Name:JACQUELINE
Other - Middle Name:NICOLE
Other - Last Name:CLINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARM D
Mailing Address - Street 1:1815 TOWNE ST
Mailing Address - Street 2:
Mailing Address - City:JOHNS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29455-3173
Mailing Address - Country:US
Mailing Address - Phone:843-446-2610
Mailing Address - Fax:843-764-0305
Practice Address - Street 1:214 SAINT JAMES AVE
Practice Address - Street 2:
Practice Address - City:GOOSE CREEK
Practice Address - State:SC
Practice Address - Zip Code:29445-2974
Practice Address - Country:US
Practice Address - Phone:843-553-3661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-16
Last Update Date:2013-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC14238183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC14238OtherSC BOP