Provider Demographics
NPI:1043518301
Name:MEDEIROS, TAMI CONNER
Entity type:Individual
Prefix:
First Name:TAMI
Middle Name:CONNER
Last Name:MEDEIROS
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 1:20825 WOODPECKER RD
Mailing Address - Street 2:
Mailing Address - City:ETTRICK
Mailing Address - State:VA
Mailing Address - Zip Code:23803-2573
Mailing Address - Country:US
Mailing Address - Phone:804-520-0224
Mailing Address - Fax:
Practice Address - Street 1:20825 WOODPECKER RD
Practice Address - Street 2:
Practice Address - City:ETTRICK
Practice Address - State:VA
Practice Address - Zip Code:23803-2573
Practice Address - Country:US
Practice Address - Phone:804-520-0224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-09
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202011369183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist