Provider Demographics
NPI:1528785672
Name:RADEV, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:RADEV
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 1:137 KINDER LN
Mailing Address - Street 2:
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-2826
Mailing Address - Country:US
Mailing Address - Phone:618-798-0677
Mailing Address - Fax:
Practice Address - Street 1:12345 SAINT CHARLES ROCK RD
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2505
Practice Address - Country:US
Practice Address - Phone:314-770-2479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-19
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022041309183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist