Provider Demographics
NPI:1639782790
Name:CRUZ, NICOLLE RAE (PHARMD)
Entity Type:Individual
Prefix:
First Name:NICOLLE
Middle Name:RAE
Last Name:CRUZ
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 AVENUE H
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:WY
Mailing Address - Zip Code:82435-2260
Mailing Address - Country:US
Mailing Address - Phone:307-754-1179
Mailing Address - Fax:307-754-7732
Practice Address - Street 1:777 AVENUE H
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:WY
Practice Address - Zip Code:82435-2260
Practice Address - Country:US
Practice Address - Phone:307-754-1179
Practice Address - Fax:307-754-7732
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY4237183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist