Provider Demographics
NPI:1952881294
Name:MCCULLOUGH, NICOLE (PHARMD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 ROBIN DR
Mailing Address - Street 2:
Mailing Address - City:KITTANNING
Mailing Address - State:PA
Mailing Address - Zip Code:16201-3434
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 BUTLER CMNS
Practice Address - Street 2:
Practice Address - City:BUTLER
Practice Address - State:PA
Practice Address - Zip Code:16001-2496
Practice Address - Country:US
Practice Address - Phone:724-282-7722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP4400481835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy SpecialistGroup - Single Specialty