Provider Demographics
NPI:1427370543
Name:WILLEY, NICO ANN (RPH)
Entity Type:Individual
Prefix:
First Name:NICO
Middle Name:ANN
Last Name:WILLEY
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 1:87 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:SHERRILL
Mailing Address - State:NY
Mailing Address - Zip Code:13461-1231
Mailing Address - Country:US
Mailing Address - Phone:315-361-4090
Mailing Address - Fax:315-361-4969
Practice Address - Street 1:87 E STATE ST
Practice Address - Street 2:
Practice Address - City:SHERRILL
Practice Address - State:NY
Practice Address - Zip Code:13461-1231
Practice Address - Country:US
Practice Address - Phone:315-361-4090
Practice Address - Fax:315-361-4969
Is Sole Proprietor?:No
Enumeration Date:2010-02-16
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042073-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist