=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558986372
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHAKELIA FOGLE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2020
-----------------------------------------------------
Last Update Date | 06/09/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 212 FRANKFORT CT
-----------------------------------------------------
City | EUTAWVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29048-9107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-378-1739
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 212 FRANKFORT CT
-----------------------------------------------------
City | EUTAWVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29048-9107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-378-1739
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183700000X
-----------------------------------------------------
Taxonomy Name | Pharmacy Technician
-----------------------------------------------------
License Number | 18057
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 172A00000X
-----------------------------------------------------
Taxonomy Name | Driver
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------