Provider Demographics
NPI:1689906893
Name:NICHOLS, SHANNON ELIZABETH (RPH)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:ELIZABETH
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10400 SUNNYLAND DR
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35405-8964
Mailing Address - Country:US
Mailing Address - Phone:205-752-3504
Mailing Address - Fax:205-752-3131
Practice Address - Street 1:635 SKYLAND BLVD
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35405-3934
Practice Address - Country:US
Practice Address - Phone:205-752-3504
Practice Address - Fax:205-752-3131
Is Sole Proprietor?:No
Enumeration Date:2010-02-12
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12934183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist