Provider Demographics
NPI:1144504887
Name:DECICCO, JACQUELINE DAYLE (PHARMD)
Entity type:Individual
Prefix:MISS
First Name:JACQUELINE
Middle Name:DAYLE
Last Name:DECICCO
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2280 N LAS VEGAS BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89030-5803
Mailing Address - Country:US
Mailing Address - Phone:702-649-1415
Mailing Address - Fax:
Practice Address - Street 1:2280 N LAS VEGAS BLVD
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-5803
Practice Address - Country:US
Practice Address - Phone:702-649-1415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-29
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV17623183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist