Basic Information
Provider Information | |||||||||
NPI: | 1689998189 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NICHOLAS | ||||||||
FirstName: | RICHARD | ||||||||
MiddleName: | S | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHARMD, ND | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 204 WINTERBROOK CIR | ||||||||
Address2: |   | ||||||||
City: | KINGSPORT | ||||||||
State: | TN | ||||||||
PostalCode: | 376634409 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2764312648 | ||||||||
FaxNumber: | 2764312082 | ||||||||
Practice Location | |||||||||
Address1: | 121 ADVANCED TECHNOLOGY DRIVE | ||||||||
Address2: |   | ||||||||
City: | DUFFIELD | ||||||||
State: | VA | ||||||||
PostalCode: | 24244 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2764312648 | ||||||||
FaxNumber: | 2764312082 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/26/2010 | ||||||||
LastUpdateDate: | 03/26/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175F00000X | NT00001647 | WA | N |   | Other Service Providers | Naturopath |   | 183500000X | 0202209727 | VA | Y |   | Pharmacy Service Providers | Pharmacist |   | 183500000X | 11096 | NV | N |   | Pharmacy Service Providers | Pharmacist |   | 183500000X | PH00044799 | WA | N |   | Pharmacy Service Providers | Pharmacist |   |
No ID Information.