Provider Demographics
NPI:1639573660
Name:BLANKS, NICOLE VOSO
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:VOSO
Last Name:BLANKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11980 HIGHWAY 17 BYP
Mailing Address - Street 2:
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576-9339
Mailing Address - Country:US
Mailing Address - Phone:843-357-2000
Mailing Address - Fax:
Practice Address - Street 1:125 MARYPORT DRIVE
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29575
Practice Address - Country:US
Practice Address - Phone:843-232-0495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-20
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12598183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist