MEDICARE: PORTIA GAJEWSKI

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	5242	SC

General Provider Information

NPI Number	:	1548689185
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PORTIA GAJEWSKI

Provider Business Mailing Address
First Line	:	2751 BEAVER RUN BLVD
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29575-5381
Country	:	US
Telephone Number	:	843-215-3856
Fax Number	:	813-215-3859

Provider Business Practice Location Address
First Line	:	2751 BEAVER RUN BLVD
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29575-5381
Country	:	US
Telephone Number	:	843-215-3856
Fax Number	:	813-215-3859

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

Provider Enumeration Date	:	04/10/2014
Last Update Date	:	04/10/2014

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Directions to “ PORTIA GAJEWSKI ” Practice Location

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