Provider Demographics
NPI:1275801920
Name:RUBALCABA-LOPEZ, NICOLE ANN (PHARMD)
Entity Type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:ANN
Last Name:RUBALCABA-LOPEZ
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 N MCCULLOCH BLVD
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81007-4444
Mailing Address - Country:US
Mailing Address - Phone:719-250-6881
Mailing Address - Fax:
Practice Address - Street 1:78 N MCCULLOCH BLVD
Practice Address - Street 2:
Practice Address - City:PUEBLO WEST
Practice Address - State:CO
Practice Address - Zip Code:81007-4444
Practice Address - Country:US
Practice Address - Phone:719-647-9925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-08
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO19263183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist