MEDICARE: TIMOTHY P CANCRO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	0202006349	VA

General Provider Information

NPI Number	:	1609174234
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIMOTHY P CANCRO

Provider Business Mailing Address
First Line	:	5500 LAKESIDE AVE
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23228-5719
Country	:	US
Telephone Number	:	804-262-6517
Fax Number	:

Provider Business Practice Location Address
First Line	:	5500 LAKESIDE AVE
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23228-5719
Country	:	US
Telephone Number	:	804-262-6517
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/07/2011
Last Update Date	:	03/07/2011

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