Provider Demographics
NPI:1528471257
Name:BEAVERS, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BEAVERS
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 1:525 LAUREL RD
Mailing Address - Street 2:
Mailing Address - City:SPRING BROOK TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:18444-6322
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1593 ELMIRA ST
Practice Address - Street 2:
Practice Address - City:SAYRE
Practice Address - State:PA
Practice Address - Zip Code:18840-9254
Practice Address - Country:US
Practice Address - Phone:570-888-2369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-10
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP446774183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist