Healthcare Provider Details

I. General information

NPI: 1063922334
Provider Name (Legal Business Name): NICOLE CHRISTINA DZIUBA PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2017
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

533 E GRANT STREET
MACOMB IL
61455
US

IV. Provider business mailing address

6 MARTY LN
MACOMB IL
61455-9504
US

V. Phone/Fax

Practice location:
  • Phone: 516-639-8151
  • Fax:
Mailing address:
  • Phone: 516-639-8151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS57090
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: