Provider Demographics
NPI:1316494131
Name:NICOL, JOHN KENNETH (PHARMD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:KENNETH
Last Name:NICOL
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 1:25 GARDEN ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-5008
Mailing Address - Country:US
Mailing Address - Phone:860-933-5771
Mailing Address - Fax:
Practice Address - Street 1:1100 SILAS DEANE HWY
Practice Address - Street 2:
Practice Address - City:WETHERSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06109-4232
Practice Address - Country:US
Practice Address - Phone:860-721-7224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-09
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0013920183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist