Provider Demographics
NPI:1407626336
Name:GRICRERIA SWITZER, NICHOLE CALEB ANASTASIA
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:CALEB ANASTASIA
Last Name:GRICRERIA SWITZER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICHOLE
Other - Middle Name:CALEB ANASTASIA
Other - Last Name:GRICRERIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1203 MARKET ST APT 401
Mailing Address - Street 2:
Mailing Address - City:PASCAGOULA
Mailing Address - State:MS
Mailing Address - Zip Code:39567-6654
Mailing Address - Country:US
Mailing Address - Phone:601-754-5032
Mailing Address - Fax:
Practice Address - Street 1:12007 LAMEY BRIDGE RD
Practice Address - Street 2:
Practice Address - City:DIBERVILLE
Practice Address - State:MS
Practice Address - Zip Code:39540-8907
Practice Address - Country:US
Practice Address - Phone:228-392-2388
Practice Address - Fax:228-392-6857
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-02
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT-227404183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician