Provider Demographics
NPI:1659761112
Name:SMITH, NICOLE RENISE (PHARMACY TECHNICIAN)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:RENISE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PHARMACY TECHNICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:936 BAY RIDGE AVE
Mailing Address - Street 2:#206
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21403-3011
Mailing Address - Country:US
Mailing Address - Phone:443-837-3541
Mailing Address - Fax:443-837-3551
Practice Address - Street 1:1911 TOWNE CENTRE BLVD
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3020
Practice Address - Country:US
Practice Address - Phone:443-837-3541
Practice Address - Fax:443-837-3551
Is Sole Proprietor?:No
Enumeration Date:2015-02-04
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDT11514183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician