Provider Demographics
NPI:1437754454
Name:MCCORMICK, KIRSTEN CLAY (RPH)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:CLAY
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:MRS
Other - First Name:KIRSTEN
Other - Middle Name:CLAY
Other - Last Name:MCCORMICK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:6090 PHILPOTT RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-6630
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3231 HALIFAX RD
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-4907
Practice Address - Country:US
Practice Address - Phone:434-572-6994
Practice Address - Fax:434-517-0070
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202011788183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist