Provider Demographics
NPI:1053030411
Name:NANAGAS, CAMERON JUSTO
Entity type:Individual
Prefix:
First Name:CAMERON
Middle Name:JUSTO
Last Name:NANAGAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1342 ELEMENT WAY APT 6306
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-1616
Mailing Address - Country:US
Mailing Address - Phone:704-718-5837
Mailing Address - Fax:
Practice Address - Street 1:8290 MARKET ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28411-9388
Practice Address - Country:US
Practice Address - Phone:910-681-1113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-26
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC31645183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist