MEDICARE: KELLY C SAMS R.PH.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	009421	SC

General Provider Information

NPI Number	:	1386952430
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY C SAMS R.PH.

Provider Business Mailing Address
First Line	:	1440 BEN SAWYER BLVD
Second Line	:
City	:	MT PLEASANT
State	:	SC
Zip	:	29464-5525
Country	:	US
Telephone Number	:	843-388-2504
Fax Number	:	843-856-0574

Provider Business Practice Location Address
First Line	:	1440 BEN SAWYER BLVD
Second Line	:
City	:	MT PLEASANT
State	:	SC
Zip	:	29464-5525
Country	:	US
Telephone Number	:	843-388-2504
Fax Number	:	843-856-0574

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/22/2010
Last Update Date	:	09/22/2010

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