Provider Demographics
NPI:1689120081
Name:NICHOLS, JACOB DANIEL (PHARMD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:DANIEL
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 CRAIG RD
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71360-6331
Mailing Address - Country:US
Mailing Address - Phone:318-229-5437
Mailing Address - Fax:
Practice Address - Street 1:2951 COTTINGHAM EXPY
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-4389
Practice Address - Country:US
Practice Address - Phone:318-640-0145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-26
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA021695183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist