Healthcare Provider Details

I. General information

NPI: 1053629519
Provider Name (Legal Business Name): DR. STACEY BASS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2010
Last Update Date: 09/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

734 N GREENWOOD AVE
WARE SHOALS SC
29692-1233
US

IV. Provider business mailing address

734 N GREENWOOD AVE
WARE SHOALS SC
29692-1233
US

V. Phone/Fax

Practice location:
  • Phone: 864-456-7512
  • Fax: 864-456-2858
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number12208
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: