Provider Demographics
NPI:1932421211
Name:NICHOLS, LISA MARIE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:NICHOLS
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 1:4950 W 23RD ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-5802
Mailing Address - Country:US
Mailing Address - Phone:814-835-0562
Mailing Address - Fax:814-835-0564
Practice Address - Street 1:4950 W 23RD ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16506-5802
Practice Address - Country:US
Practice Address - Phone:814-835-0562
Practice Address - Fax:814-835-0564
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-27
Last Update Date:2010-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP037708L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007455310178Medicaid