Provider Demographics
NPI:1144662362
Name:MANDELA, NICKETRIS SIMMONS (PHARMD)
Entity type:Individual
Prefix:MRS
First Name:NICKETRIS
Middle Name:SIMMONS
Last Name:MANDELA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13480 NW 4TH ST APT 105
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33028-2240
Mailing Address - Country:US
Mailing Address - Phone:954-235-2477
Mailing Address - Fax:
Practice Address - Street 1:5701 NW 183RD ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-6022
Practice Address - Country:US
Practice Address - Phone:305-625-0952
Practice Address - Fax:305-623-7742
Is Sole Proprietor?:No
Enumeration Date:2013-07-30
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS50810183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist