Provider Demographics
NPI:1134665557
Name:VRETTOS, ATHAN
Entity Type:Individual
Prefix:
First Name:ATHAN
Middle Name:
Last Name:VRETTOS
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 1:4540 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SHALLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28470-4446
Mailing Address - Country:US
Mailing Address - Phone:910-754-2885
Mailing Address - Fax:910-754-2887
Practice Address - Street 1:4540 MAIN ST
Practice Address - Street 2:
Practice Address - City:SHALLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28470-4446
Practice Address - Country:US
Practice Address - Phone:910-754-2885
Practice Address - Fax:910-754-2887
Is Sole Proprietor?:No
Enumeration Date:2017-01-09
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC18861183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist