Provider Demographics
NPI:1609203314
Name:CICONE, ELSIE
Entity Type:Individual
Prefix:
First Name:ELSIE
Middle Name:
Last Name:CICONE
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:PO BOX 80223
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29680-0004
Mailing Address - Country:US
Mailing Address - Phone:864-365-6583
Mailing Address - Fax:
Practice Address - Street 1:1500 WESTERN SQUARE
Practice Address - Street 2:
Practice Address - City:LAURENS
Practice Address - State:SC
Practice Address - Zip Code:29360-6664
Practice Address - Country:US
Practice Address - Phone:864-365-6583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-26
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9589183500000X
TN8250183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist