Healthcare Provider Details

I. General information

NPI: 1114270089
Provider Name (Legal Business Name): DELANA RAE CUDD RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DELANA RAE GREEN RPH

II. Dates (important events)

Enumeration Date: 10/17/2012
Last Update Date: 10/10/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2219 MAIN ST
CONWAY SC
29526-3340
US

IV. Provider business mailing address

2219 MAIN ST
CONWAY SC
29526-3340
US

V. Phone/Fax

Practice location:
  • Phone: 843-488-4400
  • Fax:
Mailing address:
  • Phone: 843-488-4400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number8985
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number12418
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: