Provider Demographics
NPI:1437379278
Name:BALLAS, NICOLETTE PHOEBE (RPH)
Entity Type:Individual
Prefix:
First Name:NICOLETTE
Middle Name:PHOEBE
Last Name:BALLAS
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 1:2320 RIVER MIST DR
Mailing Address - Street 2:
Mailing Address - City:FINKSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21048-1738
Mailing Address - Country:US
Mailing Address - Phone:410-876-9943
Mailing Address - Fax:
Practice Address - Street 1:99 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157-4800
Practice Address - Country:US
Practice Address - Phone:410-848-5980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD10313183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist