Healthcare Provider Details

I. General information

NPI: 1801292909
Provider Name (Legal Business Name): TARA MARIE MUDGE PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TARA MARIE CASTLEMAN

II. Dates (important events)

Enumeration Date: 11/17/2014
Last Update Date: 10/10/2026
Certification Date: 10/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1286 EIGHTEEN MILE RD
CENTRAL SC
29630-8605
US

IV. Provider business mailing address

1286 EIGHTEEN MILE RD
CENTRAL SC
29630-8605
US

V. Phone/Fax

Practice location:
  • Phone: 864-639-5665
  • Fax:
Mailing address:
  • Phone: 864-639-5665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH035453
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number059488
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number67683
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: