Basic Information
Provider Information | |||||||||
NPI: | 1659678118 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHEALY | ||||||||
FirstName: | WILLIAM | ||||||||
MiddleName: | JAMES | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | BS, PHARMD, CDE | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 118008 | ||||||||
Address2: |   | ||||||||
City: | NORTH CHARLESTON | ||||||||
State: | SC | ||||||||
PostalCode: | 294238008 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8435727727 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2500 ELMS CENTER RD | ||||||||
Address2: |   | ||||||||
City: | NORTH CHARLESTON | ||||||||
State: | SC | ||||||||
PostalCode: | 294069844 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8435727727 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/18/2011 | ||||||||
LastUpdateDate: | 03/24/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 13118 | SC | Y |   | Pharmacy Service Providers | Pharmacist |   | 1835N1003X | 21410352 | SC | N |   | Pharmacy Service Providers | Pharmacist | Nutrition Support | 133V00000X |   |   | N |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   | 133NN1002X |   |   | N |   | Dietary & Nutritional Service Providers | Nutritionist | Nutrition, Education |
No ID Information.