Provider Demographics
NPI:1962731398
Name:NICHOLS, JAKE (PHARMD, MBA)
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:PHARMD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:NATICK
Mailing Address - State:MA
Mailing Address - Zip Code:01760-2848
Mailing Address - Country:US
Mailing Address - Phone:617-529-6312
Mailing Address - Fax:
Practice Address - Street 1:41 WALNUT ST
Practice Address - Street 2:
Practice Address - City:NATICK
Practice Address - State:MA
Practice Address - Zip Code:01760-2848
Practice Address - Country:US
Practice Address - Phone:617-529-6312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-14
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0247521835P1300X, 1835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1300XPharmacy Service ProvidersPharmacistPsychiatric
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA024752OtherMASSACHUSETTS PHARMACY LICENSE