Basic Information
| Provider Information | |||||||||
| NPI: | 1700209905 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WYATT | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | W | ||||||||
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| Mailing Information | |||||||||
| Address1: | 203 CEDAR SPRINGS RD | ||||||||
| Address2: | |||||||||
| City: | SPARTANBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 293024639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8643816366 | ||||||||
| FaxNumber: | 8643816367 | ||||||||
| Practice Location | |||||||||
| Address1: | 203 CEDAR SPRINGS RD | ||||||||
| Address2: | |||||||||
| City: | SPARTANBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8643816366 | ||||||||
| FaxNumber: | 8643816367 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2014 | ||||||||
| LastUpdateDate: | 08/19/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 5949 | SC | Y | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | 5949 | 01 | SC | SC LIC PHARMACIST | OTHER |