Provider Demographics
NPI:1346651809
Name:WIDENER, CASSANDRA (PHARM D)
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:
Last Name:WIDENER
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:CASSANDRA
Other - Middle Name:
Other - Last Name:GILLIAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1624 NC HIGHWAY 14
Mailing Address - Street 2:
Mailing Address - City:REIDSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27320-9666
Mailing Address - Country:US
Mailing Address - Phone:336-349-2325
Mailing Address - Fax:336-349-2418
Practice Address - Street 1:1624 NC HIGHWAY 14
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-9666
Practice Address - Country:US
Practice Address - Phone:336-349-2325
Practice Address - Fax:336-349-2418
Is Sole Proprietor?:No
Enumeration Date:2014-05-17
Last Update Date:2014-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23397183500000X
VA0202212625183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist