Provider Demographics
NPI:1609174234
Name:CANCRO, TIMOTHY P
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:P
Last Name:CANCRO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 LAKESIDE AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23228-5719
Mailing Address - Country:US
Mailing Address - Phone:804-262-6517
Mailing Address - Fax:
Practice Address - Street 1:5500 LAKESIDE AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23228-5719
Practice Address - Country:US
Practice Address - Phone:804-262-6517
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-07
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202006349183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist