Provider Demographics
NPI:1356475792
Name:NICOLAS, BERNADETTE CRUZ (RPH)
Entity Type:Individual
Prefix:
First Name:BERNADETTE
Middle Name:CRUZ
Last Name:NICOLAS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3206 REGENCY CT
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-7622
Mailing Address - Country:US
Mailing Address - Phone:423-313-4847
Mailing Address - Fax:
Practice Address - Street 1:3040 BATTLEFIELD PKWY
Practice Address - Street 2:
Practice Address - City:FORT OGLETHORPE
Practice Address - State:GA
Practice Address - Zip Code:30742-4004
Practice Address - Country:US
Practice Address - Phone:706-861-6252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN23119183500000X
GARPH023558183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist