Provider Demographics
NPI:1871995738
Name:NICOLAS, AMANDA RAROGAL
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:RAROGAL
Last Name:NICOLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2011 E LAKE MEAD BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89030-7135
Mailing Address - Country:US
Mailing Address - Phone:702-642-9780
Mailing Address - Fax:
Practice Address - Street 1:2011 E LAKE MEAD BLVD
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-7135
Practice Address - Country:US
Practice Address - Phone:702-642-9780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-23
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60467165183500000X
NV18987183500000X
HI3847183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist