Provider Demographics
NPI:1386930741
Name:NICKERSON, RICKY (RPH)
Entity type:Individual
Prefix:MR
First Name:RICKY
Middle Name:
Last Name:NICKERSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4271 TAMIAMI TRL S
Mailing Address - Street 2:T-0813
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34293-5131
Mailing Address - Country:US
Mailing Address - Phone:941-497-7885
Mailing Address - Fax:941-497-7885
Practice Address - Street 1:4271 TAMIAMI TRL S
Practice Address - Street 2:T-0813
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34293-5131
Practice Address - Country:US
Practice Address - Phone:941-497-7885
Practice Address - Fax:941-497-7885
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-23
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL32464183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist