Provider Demographics
NPI:1649285255
Name:NADA VICIJAN
Entity type:Organization
Organization Name:NADA VICIJAN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:NADA
Authorized Official - Middle Name:
Authorized Official - Last Name:VICIJAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-529-0325
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CA520733336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2152349OtherPK
CA1649285255Medicaid
7532810001Medicare NSC