Provider Demographics
NPI:1336796044
Name:NICHOLS, ALISA (RPH)
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:ALISA
Other - Middle Name:
Other - Last Name:STONE-CRAWFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:4625 E MARYLAND ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-5092
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4625 E MARYLAND ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-5092
Practice Address - Country:US
Practice Address - Phone:217-864-9288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-19
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051037047183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL051037047OtherILLINOS LICENSE NUMBER