Provider Demographics
NPI:1316062318
Name:YANICKO, THOMAS M (RPH)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:M
Last Name:YANICKO
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7328 WEBBS CHAPEL COVE CT
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:NC
Mailing Address - Zip Code:28037-6508
Mailing Address - Country:US
Mailing Address - Phone:724-316-0598
Mailing Address - Fax:
Practice Address - Street 1:521 E PLAZA DR
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28115-8071
Practice Address - Country:US
Practice Address - Phone:704-658-9870
Practice Address - Fax:704-658-9871
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP-032010L183500000X
NC28427183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist