Provider Demographics
NPI:1083097315
Name:VARGAS, NICOLO EDDIE QUINZON
Entity Type:Individual
Prefix:
First Name:NICOLO EDDIE
Middle Name:QUINZON
Last Name:VARGAS
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 1:103 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28301-7603
Mailing Address - Country:US
Mailing Address - Phone:910-488-1033
Mailing Address - Fax:910-488-1476
Practice Address - Street 1:103 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-7603
Practice Address - Country:US
Practice Address - Phone:910-488-1033
Practice Address - Fax:910-488-1476
Is Sole Proprietor?:No
Enumeration Date:2015-07-06
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC25295183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist