Provider Demographics
NPI:1861168650
Name:NICELY, KEVIN A (RPH)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:A
Last Name:NICELY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 MOUNTAINEER DR
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:WV
Mailing Address - Zip Code:26807-8000
Mailing Address - Country:US
Mailing Address - Phone:304-358-3272
Mailing Address - Fax:
Practice Address - Street 1:71 MOUNTAINEER DR
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:WV
Practice Address - Zip Code:26807-8000
Practice Address - Country:US
Practice Address - Phone:304-358-3272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-20
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0012783183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist