Provider Demographics
NPI:1720537004
Name:CROSS, NICHOLE (RPH)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:CROSS
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 1:714 FAWN CIR
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-3134
Mailing Address - Country:US
Mailing Address - Phone:803-773-8666
Mailing Address - Fax:803-775-5641
Practice Address - Street 1:40 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-4946
Practice Address - Country:US
Practice Address - Phone:803-773-8112
Practice Address - Fax:803-775-5641
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-27
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7871183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist