Provider Demographics
NPI:1164022133
Name:POLAND, CONSTANCE WHITTEMORE
Entity type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:WHITTEMORE
Last Name:POLAND
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 1:303 MARKET DR
Mailing Address - Street 2:
Mailing Address - City:EMPORIA
Mailing Address - State:VA
Mailing Address - Zip Code:23847-1203
Mailing Address - Country:US
Mailing Address - Phone:434-336-9310
Mailing Address - Fax:
Practice Address - Street 1:303 MARKET DR
Practice Address - Street 2:
Practice Address - City:EMPORIA
Practice Address - State:VA
Practice Address - Zip Code:23847-1203
Practice Address - Country:US
Practice Address - Phone:434-336-9310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202009176183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist