Provider Demographics
NPI:1033587498
Name:NICOLETTE, JOHN JR
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:NICOLETTE
Suffix:JR
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 1:3383 BASS LAKE RD
Mailing Address - Street 2:
Mailing Address - City:EL DORADO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:95762-6623
Mailing Address - Country:US
Mailing Address - Phone:530-313-4925
Mailing Address - Fax:530-313-4926
Practice Address - Street 1:3383 BASS LAKE RD
Practice Address - Street 2:
Practice Address - City:EL DORADO HILLS
Practice Address - State:CA
Practice Address - Zip Code:95762-6623
Practice Address - Country:US
Practice Address - Phone:530-313-4925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-02
Last Update Date:2022-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA73065183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist