Provider Demographics
NPI:1962825554
Name:FOTIADIS, NICKI (RPH)
Entity Type:Individual
Prefix:
First Name:NICKI
Middle Name:
Last Name:FOTIADIS
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 1:420 COVERED WAGON DR
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-1741
Mailing Address - Country:US
Mailing Address - Phone:909-610-5823
Mailing Address - Fax:
Practice Address - Street 1:12835 MOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-4556
Practice Address - Country:US
Practice Address - Phone:909-548-6366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-02
Last Update Date:2014-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61570183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist