Provider Demographics
NPI:1578009049
Name:MCCORMICK, CONNIE ANN
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:ANN
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:ANN
Other - Last Name:GLEISNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:2500 FOREST HILLS RD W
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893-3461
Mailing Address - Country:US
Mailing Address - Phone:252-243-7396
Mailing Address - Fax:252-243-7782
Practice Address - Street 1:2500 FOREST HILLS RD W
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-3461
Practice Address - Country:US
Practice Address - Phone:252-243-7396
Practice Address - Fax:252-243-7782
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-09
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC17968183500000X
VA0202010566183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist