Healthcare Provider Details

I. General information

NPI: 1619795028
Provider Name (Legal Business Name): SARAH WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2024
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 RUTLEDGE AVE RM 106
CHARLESTON SC
29425-8903
US

IV. Provider business mailing address

135 RUTLEDGE AVE RM 106
CHARLESTON SC
29425-8903
US

V. Phone/Fax

Practice location:
  • Phone: 843-876-0199
  • Fax:
Mailing address:
  • Phone: 843-876-0199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number60393
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: