Healthcare Provider Details

I. General information

NPI: 1528577996
Provider Name (Legal Business Name): TERESA ANN CICCI PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2017
Last Update Date: 09/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MEDICAL CENTER BOULEVARD
WINSTON SALEM NC
27157-0001
US

IV. Provider business mailing address

411 PARK RIDGE LN APT D
WINSTON SALEM NC
27104-3560
US

V. Phone/Fax

Practice location:
  • Phone: 336-713-8785
  • Fax: 336-713-3434
Mailing address:
  • Phone: 570-259-8965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number24415
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: