Basic Information
| Provider Information | |||||||||
| NPI: | 1427569987 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KENNEDY | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 345 EDENWOOD DR | ||||||||
| Address2: | |||||||||
| City: | SUMTER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291548141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034642050 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 343 PINEWOOD RD | ||||||||
| Address2: | |||||||||
| City: | SUMTER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291505442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033056237 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2017 | ||||||||
| LastUpdateDate: | 05/05/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 37399 | SC | Y | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | 37399 | 01 | SC | SC PHARMACY LICENSE | OTHER | 1427569987 | 01 | SC | NPI | OTHER |