=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871122440
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NATASHA NICOLETTE COLVIN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2020
-----------------------------------------------------
Last Update Date | 04/06/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 422 N FRASER ST
-----------------------------------------------------
City | GEORGETOWN
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29440-3260
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-904-9257
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 88 CHESTER AVE
-----------------------------------------------------
City | GREAT FALLS
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29055-8871
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-209-5725
-----------------------------------------------------
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 | 37051
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------