Provider Demographics
NPI:1629486956
Name:VICIJAN, NADA (RPH)
Entity Type:Individual
Prefix:MRS
First Name:NADA
Middle Name:
Last Name:VICIJAN
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 1:314 I ST
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95351-2826
Mailing Address - Country:US
Mailing Address - Phone:209-529-0325
Mailing Address - Fax:209-529-0333
Practice Address - Street 1:314 I ST
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95351-2826
Practice Address - Country:US
Practice Address - Phone:209-529-0325
Practice Address - Fax:209-529-0333
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-30
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH41607183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7532810001Medicare NSC