Basic Information
| Provider Information | |||||||||
| NPI: | 1912423153 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAIL | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | VIVAS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PHARMD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DAIL | ||||||||
| OtherFirstName: | GINGER | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PHARMD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 200 N BELTLINE DR | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295017403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437586087 | ||||||||
| FaxNumber: | 8437586088 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 N BELTLINE DR | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295017403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437586087 | ||||||||
| FaxNumber: | 8437586088 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2017 | ||||||||
| LastUpdateDate: | 08/18/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835P0018X | 9181 | SC | Y | 193400000X SINGLE SPECIALTY GROUP | Pharmacy Service Providers | Pharmacist | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist |
No ID Information.