Healthcare Provider Details

I. General information

NPI: 1326111097
Provider Name (Legal Business Name): VICKI MCCONKEY BOOZER RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1308 LAUREL ST
COLUMBIA SC
29201-2514
US

IV. Provider business mailing address

110 EDWARD CT
COLUMBIA SC
29205-2710
US

V. Phone/Fax

Practice location:
  • Phone: 803-931-8123
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number4438
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: