Provider Demographics
NPI:1346813219
Name:ELLIOTT-FOWLER, CONSTANCE RAE
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:RAE
Last Name:ELLIOTT-FOWLER
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 1:3635 W WATER ST APT D
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-2494
Mailing Address - Country:US
Mailing Address - Phone:810-292-1499
Mailing Address - Fax:
Practice Address - Street 1:2910 PINE GROVE AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-1976
Practice Address - Country:US
Practice Address - Phone:810-987-3663
Practice Address - Fax:810-987-1411
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-20
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183700000XPharmacy Service ProvidersPharmacy TechnicianGroup - Single Specialty