Basic Information
| Provider Information | |||||||||
| NPI: | 1659791622 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | STUART | ||||||||
| MiddleName: | LEE | ||||||||
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| NameSuffix: | |||||||||
| Credential: | PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 513 N DUNCAN BYP | ||||||||
| Address2: | |||||||||
| City: | UNION | ||||||||
| State: | SC | ||||||||
| PostalCode: | 293798682 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644276114 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 513 N DUNCAN BYP | ||||||||
| Address2: | |||||||||
| City: | UNION | ||||||||
| State: | SC | ||||||||
| PostalCode: | 293798682 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644276114 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2014 | ||||||||
| LastUpdateDate: | 04/17/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 13057 | SC | Y | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | 4217053 | 01 | SC | NABP | OTHER |