Healthcare Provider Details

I. General information

NPI: 1487437810
Provider Name (Legal Business Name): SHAMAI AVIONA WYATT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2023
Last Update Date: 08/17/2023
Certification Date: 08/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3681 BOILING SPRINGS RD
BOILING SPRINGS SC
29316-6021
US

IV. Provider business mailing address

1410 PARAPET FORT DR APT 104
DUNCAN SC
29334-7625
US

V. Phone/Fax

Practice location:
  • Phone: 864-578-2414
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number44041
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: