Provider Demographics
NPI:1740565076
Name:YANICKO, RYAN THOMAS (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:THOMAS
Last Name:YANICKO
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 E PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28115-8071
Mailing Address - Country:US
Mailing Address - Phone:704-658-9870
Mailing Address - Fax:704-658-9871
Practice Address - Street 1:521 E PLAZA DR
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28115-8071
Practice Address - Country:US
Practice Address - Phone:704-658-9870
Practice Address - Fax:704-658-9871
Is Sole Proprietor?:No
Enumeration Date:2011-10-18
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP446115183500000X
NC21998183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist