Provider Demographics
NPI:1629678073
Name:NICHOLSON, PATRICIA KIEFFER
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:KIEFFER
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 SCENIC DR
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:AR
Mailing Address - Zip Code:71655-9491
Mailing Address - Country:US
Mailing Address - Phone:870-723-1385
Mailing Address - Fax:
Practice Address - Street 1:427 HIGHWAY 425 N
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:AR
Practice Address - Zip Code:71655-4015
Practice Address - Country:US
Practice Address - Phone:870-367-3559
Practice Address - Fax:870-367-5086
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD06965183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist