Provider Demographics
NPI:1326657685
Name:CICCOCIOPPO, DOMINIC
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:
Last Name:CICCOCIOPPO
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 1:454 DARLINGTON AVE APT 208
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-1879
Mailing Address - Country:US
Mailing Address - Phone:717-592-0340
Mailing Address - Fax:
Practice Address - Street 1:3625 S COLLEGE RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412-2003
Practice Address - Country:US
Practice Address - Phone:910-395-8248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-23
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC29640183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist