=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063642288
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAYCE SHEALY PHARM.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2009
-----------------------------------------------------
Last Update Date | 09/29/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 307 N BROAD ST
-----------------------------------------------------
City | CLINTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29325-2305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-938-3857
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 307 N BROAD ST
-----------------------------------------------------
City | CLINTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29325-2305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-938-3857
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | RPH025009
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1835P0018X
-----------------------------------------------------
Taxonomy Name | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
-----------------------------------------------------
License Number | 12702
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------