Provider Demographics
NPI:1841831294
Name:BALL, NICOLE (PHARMD, RPH)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BALL
Suffix:
Gender:F
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 TINKER ST
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:NY
Mailing Address - Zip Code:12498-1238
Mailing Address - Country:US
Mailing Address - Phone:845-679-0790
Mailing Address - Fax:
Practice Address - Street 1:79 TINKER ST
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:NY
Practice Address - Zip Code:12498-1238
Practice Address - Country:US
Practice Address - Phone:845-679-0790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-07
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053706183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY053706OtherPHARMACIST LICENSE