Healthcare Provider Details

I. General information

NPI: 1831447655
Provider Name (Legal Business Name): JENNIFER LYNN MIXSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2012
Last Update Date: 08/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8538 KENNESTONE LN
NORTH CHARLESTON SC
29420-6843
US

IV. Provider business mailing address

8538 KENNESTONE LN
NORTH CHARLESTON SC
29420-6843
US

V. Phone/Fax

Practice location:
  • Phone: 843-725-9886
  • Fax:
Mailing address:
  • Phone: 843-725-9886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number11823
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: