Provider Demographics
NPI:1326324302
Name:VERNON, NICOLE RAY (PHARM D)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:RAY
Last Name:VERNON
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4415 DOUGLAS AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50310-2717
Mailing Address - Country:US
Mailing Address - Phone:515-279-4739
Mailing Address - Fax:515-279-0254
Practice Address - Street 1:4415 DOUGLAS AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50310-2717
Practice Address - Country:US
Practice Address - Phone:515-279-4739
Practice Address - Fax:515-279-0254
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-22
Last Update Date:2011-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA19515183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist