Provider Demographics
NPI:1467736991
Name:VARUGHESE, TICY (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:TICY
Middle Name:
Last Name:VARUGHESE
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5005 DOUGLAS AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53402-2027
Mailing Address - Country:US
Mailing Address - Phone:262-639-9241
Mailing Address - Fax:262-639-0840
Practice Address - Street 1:5005 DOUGLAS AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53402-2027
Practice Address - Country:US
Practice Address - Phone:262-639-9241
Practice Address - Fax:262-639-0840
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-03
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15421-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist