Provider Demographics
NPI:1982140794
Name:NICHOLS, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 DEERFIELD DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT HOLLY
Mailing Address - State:NC
Mailing Address - Zip Code:28120-3100
Mailing Address - Country:US
Mailing Address - Phone:518-207-5221
Mailing Address - Fax:
Practice Address - Street 1:7131 HIGHWAY 73
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:NC
Practice Address - Zip Code:28037-9186
Practice Address - Country:US
Practice Address - Phone:704-827-8228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-17
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC17810183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist