Healthcare Provider Details

I. General information

NPI: 1831107507
Provider Name (Legal Business Name): MRS. ELIZABETH C JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 S BROAD ST
CLINTON SC
29325-2505
US

IV. Provider business mailing address

4616 INDIAN CREEK RD
KINARDS SC
29355-9353
US

V. Phone/Fax

Practice location:
  • Phone: 864-833-4000
  • Fax: 864-833-6459
Mailing address:
  • Phone: 864-697-5828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number15245
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: