Provider Demographics
NPI:1275719189
Name:STITT, CONSTANCE SUZETTE (RPH)
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:SUZETTE
Last Name:STITT
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:684 MACELROY RD
Mailing Address - Street 2:
Mailing Address - City:BALLSTON LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12019-2202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:79 VANDENBURGH AVE
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-6024
Practice Address - Country:US
Practice Address - Phone:518-272-1355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-10
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY32015183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00818759Medicaid