Provider Demographics
NPI:1720565120
Name:WILLIS, PATRICIA M (BS)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:M
Last Name:WILLIS
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 RIDGEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:ELLINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06029-3634
Mailing Address - Country:US
Mailing Address - Phone:860-597-7754
Mailing Address - Fax:
Practice Address - Street 1:80 TOWN LINE RD
Practice Address - Street 2:
Practice Address - City:ROCKY HILL
Practice Address - State:CT
Practice Address - Zip Code:06067-1249
Practice Address - Country:US
Practice Address - Phone:860-563-4462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-27
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6353183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist