Provider Demographics
NPI:1972232247
Name:STEVENSON, NICHOLAS SHAWN
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:SHAWN
Last Name:STEVENSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 ASHLEY DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-9153
Mailing Address - Country:US
Mailing Address - Phone:252-333-6905
Mailing Address - Fax:
Practice Address - Street 1:101 W EHRINGHAUS ST
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-4921
Practice Address - Country:US
Practice Address - Phone:252-338-3933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-10
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC06707183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist