Provider Demographics
NPI:1053076984
Name:THOMAS, CANDICE RENEE
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:RENEE
Last Name:THOMAS
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 1:475 KEMPSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-3721
Mailing Address - Country:US
Mailing Address - Phone:757-748-5719
Mailing Address - Fax:
Practice Address - Street 1:475 KEMPSVILLE RD
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-3721
Practice Address - Country:US
Practice Address - Phone:757-447-9224
Practice Address - Fax:757-447-9225
Is Sole Proprietor?:No
Enumeration Date:2021-11-04
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0230020409183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician