Provider Demographics
NPI:1588971774
Name:WORMACK-WALKER, CONSTANCE INEZ VANESSA (PHARMD)
Entity type:Individual
Prefix:DR
First Name:CONSTANCE
Middle Name:INEZ VANESSA
Last Name:WORMACK-WALKER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:DR
Other - First Name:CONSTANCE
Other - Middle Name:INEZ VANESSA
Other - Last Name:WORMACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:11908 MUNBURY DR
Mailing Address - Street 2:
Mailing Address - City:DADE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33525-5749
Mailing Address - Country:US
Mailing Address - Phone:352-567-8119
Mailing Address - Fax:352-567-8119
Practice Address - Street 1:11908 MUNBURY DR
Practice Address - Street 2:
Practice Address - City:DADE CITY
Practice Address - State:FL
Practice Address - Zip Code:33525-5749
Practice Address - Country:US
Practice Address - Phone:352-567-8119
Practice Address - Fax:352-567-8119
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-09
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS00319561835P0018X
GARPH0248021835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS0031956OtherDOH PHARMACIST LICENSE