Healthcare Provider Details

I. General information

NPI: 1487103529
Provider Name (Legal Business Name): BRIAN CICCONE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2016
Last Update Date: 09/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3773 OLENTANGY RIVER RD
COLUMBUS OH
43214-3425
US

IV. Provider business mailing address

3773 OLENTANGY RIVER RD
COLUMBUS OH
43214-3425
US

V. Phone/Fax

Practice location:
  • Phone: 614-566-4758
  • Fax: 614-553-0520
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03136098
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: