Provider Demographics
NPI:1629678412
Name:TAZEM, CONSTANCE MAFOR
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:MAFOR
Last Name:TAZEM
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 1:150 SOLOMONS ISLAND RD N
Mailing Address - Street 2:
Mailing Address - City:PRINCE FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:20678-3906
Mailing Address - Country:US
Mailing Address - Phone:301-221-0326
Mailing Address - Fax:410-535-6590
Practice Address - Street 1:150 SOLOMONS ISLAND RD N
Practice Address - Street 2:
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678-3906
Practice Address - Country:US
Practice Address - Phone:301-221-0326
Practice Address - Fax:410-535-6590
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD14348183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist