=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053665265
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. ELIZABETH ROLLER DORNBLASER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2012
-----------------------------------------------------
Last Update Date | 11/09/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2500 BROAD ST
-----------------------------------------------------
City | CAMDEN
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29020-2225
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-432-5103
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2131 868 COTTESMORE LANE
-----------------------------------------------------
City | CAMDEN
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29020-8003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-424-1480
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1835P0018X
-----------------------------------------------------
Taxonomy Name | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
-----------------------------------------------------
License Number | 4680
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------