Provider Demographics
NPI:1710132048
Name:BRYAN, NICKI
Entity Type:Individual
Prefix:MRS
First Name:NICKI
Middle Name:
Last Name:BRYAN
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 1:991 ALABAMA HIGHWAY 203
Mailing Address - Street 2:
Mailing Address - City:ELBA
Mailing Address - State:AL
Mailing Address - Zip Code:36323-4228
Mailing Address - Country:US
Mailing Address - Phone:334-897-5222
Mailing Address - Fax:334-897-5266
Practice Address - Street 1:991 ALABAMA HIGHWAY 203
Practice Address - Street 2:
Practice Address - City:ELBA
Practice Address - State:AL
Practice Address - Zip Code:36323-4228
Practice Address - Country:US
Practice Address - Phone:334-897-5222
Practice Address - Fax:334-897-5266
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-01
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL13244183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist