Provider Demographics
NPI:1992350680
Name:DIEMMA, NICOLAS RUSSELL
Entity type:Individual
Prefix:
First Name:NICOLAS
Middle Name:RUSSELL
Last Name:DIEMMA
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 1:433 STOBHILL LN
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:27540-7248
Mailing Address - Country:US
Mailing Address - Phone:609-670-2002
Mailing Address - Fax:
Practice Address - Street 1:2902 FORESTVILLE RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27616-8774
Practice Address - Country:US
Practice Address - Phone:919-266-6418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-08
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC28519183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist