Provider Demographics
NPI:1598455362
Name:BUSTROS, NICOLAS
Entity Type:Individual
Prefix:
First Name:NICOLAS
Middle Name:
Last Name:BUSTROS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3105 DISTRICT AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22901-2894
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:28 ABBY RD
Practice Address - Street 2:
Practice Address - City:PALMYRA
Practice Address - State:VA
Practice Address - Zip Code:22963-2085
Practice Address - Country:US
Practice Address - Phone:434-589-2278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-15
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202220482183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist