Provider Demographics
NPI:1962804617
Name:SHAUGHNESSY, NIKOLAS (PHARMD)
Entity type:Individual
Prefix:DR
First Name:NIKOLAS
Middle Name:
Last Name:SHAUGHNESSY
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 BENTON BLVD APT 3307
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-5146
Mailing Address - Country:US
Mailing Address - Phone:217-691-0512
Mailing Address - Fax:
Practice Address - Street 1:705 ELM ST W
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:SC
Practice Address - Zip Code:29924-3105
Practice Address - Country:US
Practice Address - Phone:803-943-4446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-24
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC35745183500000X
GA028080183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist