Provider Demographics
NPI:1619166410
Name:NICKERSON, SHELLY R (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:SHELLY
Middle Name:R
Last Name:NICKERSON
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 1:22319 RUFF RD
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:NE
Mailing Address - Zip Code:68028-7304
Mailing Address - Country:US
Mailing Address - Phone:402-471-9379
Mailing Address - Fax:402-742-2348
Practice Address - Street 1:828 LAKE AVE
Practice Address - Street 2:STE F
Practice Address - City:GOTHENBURG
Practice Address - State:NE
Practice Address - Zip Code:69138-1950
Practice Address - Country:US
Practice Address - Phone:308-537-2294
Practice Address - Fax:308-537-2256
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-17
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE12439183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist