MEDICARE: NICHOLAS JOHN LOMENZO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	26459	NC

General Provider Information

NPI Number	:	1114472131
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLAS JOHN LOMENZO

Provider Business Mailing Address
First Line	:	306 E WOODLAWN RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28217-2349
Country	:	US
Telephone Number	:	704-525-7291
Fax Number	:

Provider Business Practice Location Address
First Line	:	306 E WOODLAWN RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28217-2349
Country	:	US
Telephone Number	:	704-525-7291
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2016
Last Update Date	:	08/19/2016

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