Provider Demographics
NPI:1629024476
Name:VICKERY, DIANNE ANGEL (RPH)
Entity Type:Individual
Prefix:
First Name:DIANNE
Middle Name:ANGEL
Last Name:VICKERY
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 1:534 BRICK YARD RD
Mailing Address - Street 2:
Mailing Address - City:HAMPSTEAD
Mailing Address - State:NC
Mailing Address - Zip Code:28443-8209
Mailing Address - Country:US
Mailing Address - Phone:910-270-3791
Mailing Address - Fax:
Practice Address - Street 1:NAVAL HOSPITAL
Practice Address - Street 2:100 BREWSTER BLVD
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28547
Practice Address - Country:US
Practice Address - Phone:910-450-4136
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6174183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist