Individual
ALISA NICHOLS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
RPH
Contact information
Practice address
4625 E MARYLAND ST, DECATUR, IL 62521-5092
(217) 864-9288
Mailing address
4625 E MARYLAND ST, DECATUR, IL 62521-5092
Taxonomy
Speciality
Code
Description
License number
State
183500000X
Pharmacist
Primary
051037047
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
051037047
ILLINOS LICENSE NUMBER
IL
Enumeration date
08/19/2019
Last updated
08/19/2019
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