Provider Demographics
NPI:1588874002
Name:CLEMONS, NICHELLE (RPH)
Entity type:Individual
Prefix:
First Name:NICHELLE
Middle Name:
Last Name:CLEMONS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3354 MOSSWOOD LANE
Mailing Address - Street 2:
Mailing Address - City:REX
Mailing Address - State:GA
Mailing Address - Zip Code:30273-2169
Mailing Address - Country:US
Mailing Address - Phone:770-960-6047
Mailing Address - Fax:
Practice Address - Street 1:3354 MOSSWOOD LANE
Practice Address - Street 2:
Practice Address - City:REX
Practice Address - State:GA
Practice Address - Zip Code:30273-2169
Practice Address - Country:US
Practice Address - Phone:770-960-6047
Practice Address - Fax:770-960-1705
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPHO17206183500000X
FLPS29225183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist