Provider Demographics
NPI:1689142077
Name:STEFANADIS, CONSTANTINE
Entity Type:Individual
Prefix:
First Name:CONSTANTINE
Middle Name:
Last Name:STEFANADIS
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 1:237 CHIVAS DR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-8008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1906 BELLEVIEW AVE SE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-1838
Practice Address - Country:US
Practice Address - Phone:540-853-0961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-05
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC25107183500000X
VA202214040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist