Healthcare Provider Details

I. General information

NPI: 1972336931
Provider Name (Legal Business Name): SHANDI LEE PACK PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2024
Last Update Date: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

876 W FARIS RD
GREENVILLE SC
29605-4253
US

IV. Provider business mailing address

876 W FARIS RD
GREENVILLE SC
29605-4253
US

V. Phone/Fax

Practice location:
  • Phone: 864-455-3645
  • Fax: 864-455-3927
Mailing address:
  • Phone: 864-455-3645
  • Fax: 864-455-3927

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number35701
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number35701
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: