Provider Demographics
NPI:1679808059
Name:VICK, HEATHER RENEE
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:RENEE
Last Name:VICK
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 1:4577 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SHALLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28470-4447
Mailing Address - Country:US
Mailing Address - Phone:910-755-5953
Mailing Address - Fax:
Practice Address - Street 1:4577 MAIN ST
Practice Address - Street 2:
Practice Address - City:SHALLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28470-4447
Practice Address - Country:US
Practice Address - Phone:910-755-5953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-02
Last Update Date:2009-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20467183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist