Provider Demographics
NPI:1235594714
Name:NIEZGODA, VINCENT CASIMIR
Entity Type:Individual
Prefix:MR
First Name:VINCENT
Middle Name:CASIMIR
Last Name:NIEZGODA
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:VINCENT
Other - Middle Name:CASIMIR
Other - Last Name:NIEZGODA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:650 E INDIAN SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-1839
Mailing Address - Country:US
Mailing Address - Phone:602-277-5551
Mailing Address - Fax:
Practice Address - Street 1:650 E INDIAN SCHOOL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-1839
Practice Address - Country:US
Practice Address - Phone:602-277-5551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-28
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ007963183500000X
PARP031885L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist