Healthcare Provider Details

I. General information

NPI: 1609203314
Provider Name (Legal Business Name): ELSIE CICONE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2013
Last Update Date: 02/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 WESTERN SQUARE
LAURENS SC
29360-6664
US

IV. Provider business mailing address

PO BOX 80223
SIMPSONVILLE SC
29680-0004
US

V. Phone/Fax

Practice location:
  • Phone: 864-365-6583
  • Fax:
Mailing address:
  • Phone: 864-365-6583
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number9589
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number8250
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: