Provider Demographics
NPI:1336491190
Name:PETRICONE, CONSTANCE K (RPH)
Entity Type:Individual
Prefix:MRS
First Name:CONSTANCE
Middle Name:K
Last Name:PETRICONE
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 1:219 PINE HILL RD
Mailing Address - Street 2:
Mailing Address - City:CHELMSFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01824-1976
Mailing Address - Country:US
Mailing Address - Phone:978-250-3327
Mailing Address - Fax:
Practice Address - Street 1:133 ORNAC
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-4159
Practice Address - Country:US
Practice Address - Phone:978-287-3770
Practice Address - Fax:978-287-3670
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-03
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA17608183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist