Provider Demographics
NPI:1588427355
Name:NICHOLAS, MARIETTA
Entity type:Individual
Prefix:
First Name:MARIETTA
Middle Name:
Last Name:NICHOLAS
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 1:4687 SPRUCE CT UNIT 1
Mailing Address - Street 2:
Mailing Address - City:JB ANDREWS
Mailing Address - State:MD
Mailing Address - Zip Code:20762-5403
Mailing Address - Country:US
Mailing Address - Phone:915-299-3528
Mailing Address - Fax:
Practice Address - Street 1:7546 ANNAPOLIS RD
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20784-1702
Practice Address - Country:US
Practice Address - Phone:301-577-6128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD296191835P0018X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist