Provider Demographics
NPI:1083396899
Name:GANLY, NICHOLAS JAMES (PHARMD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JAMES
Last Name:GANLY
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 HURLEY ST APT 1
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02141-2386
Mailing Address - Country:US
Mailing Address - Phone:812-605-9296
Mailing Address - Fax:
Practice Address - Street 1:1199 CENTRE ST
Practice Address - Street 2:
Practice Address - City:NEWTON CENTRE
Practice Address - State:MA
Practice Address - Zip Code:02459-1534
Practice Address - Country:US
Practice Address - Phone:617-332-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-01
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH241595183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist