Provider Demographics
NPI:1942564208
Name:MCCORMICK, ASHLEY NICOLE
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:NICOLE
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ASHELY
Other - Middle Name:NICOLE
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:719 S STATE ROAD 19
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-3946
Mailing Address - Country:US
Mailing Address - Phone:386-328-6787
Mailing Address - Fax:
Practice Address - Street 1:719 S STATE ROAD 19
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-3946
Practice Address - Country:US
Practice Address - Phone:386-328-6787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-01
Last Update Date:2012-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRPT38478183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician