Provider Demographics
NPI:1962481697
Name:NICHOLAS PHARMACY INC
Entity Type:Organization
Organization Name:NICHOLAS PHARMACY INC
Other - Org Name:NICHOLAS HOME MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:RRT
Authorized Official - Phone:304-872-0517
Mailing Address - Street 1:421 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SUMMERSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26651-1343
Mailing Address - Country:US
Mailing Address - Phone:304-872-0517
Mailing Address - Fax:304-872-6644
Practice Address - Street 1:421 MAIN ST
Practice Address - Street 2:
Practice Address - City:SUMMERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26651
Practice Address - Country:US
Practice Address - Phone:304-872-0517
Practice Address - Fax:304-872-6644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-11
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 332BX2000X, 332BX2000X
WVSP05523263336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0143752000Medicaid
2109949OtherPK
2109949OtherPK