Healthcare Provider Details

I. General information

NPI: 1114063773
Provider Name (Legal Business Name): MR. ROBERT KEELS WYLIE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 CHURCH ST
CHESTER SC
29706-2903
US

IV. Provider business mailing address

741 GRANT LAKES CIRCLE P O BOX 505
CHESTER SC
29706
US

V. Phone/Fax

Practice location:
  • Phone: 803-581-2102
  • Fax: 803-581-2121
Mailing address:
  • Phone: 803-581-7054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5417
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: