Provider Demographics
NPI:1306437421
Name:PROVENZANO, ELISABETH THOMPSON (RPH)
Entity type:Individual
Prefix:MS
First Name:ELISABETH
Middle Name:THOMPSON
Last Name:PROVENZANO
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:MISS
Other - First Name:ELISABETH
Other - Middle Name:MARIE
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:221 W RESERVOIR RD
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:VA
Mailing Address - Zip Code:22664-1001
Mailing Address - Country:US
Mailing Address - Phone:540-459-8311
Mailing Address - Fax:540-459-4651
Practice Address - Street 1:221 W RESERVOIR RD
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:VA
Practice Address - Zip Code:22664-1001
Practice Address - Country:US
Practice Address - Phone:540-459-8311
Practice Address - Fax:540-459-4651
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-01
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy