Healthcare Provider Details

I. General information

NPI: 1053394387
Provider Name (Legal Business Name): MRS. MARY JOETTE MCCOY
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/21/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 MILLS AVE UNIT #5
GREENVILLE SC
29605-4070
US

IV. Provider business mailing address

310 MCMAKIN DR
GREENVILLE SC
29609
US

V. Phone/Fax

Practice location:
  • Phone: 864-232-9860
  • Fax: 864-232-9860
Mailing address:
  • Phone: 864-233-8194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number14420
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: