Provider Demographics
NPI:1124847371
Name:WILM, THARYAR MYATNOE
Entity type:Individual
Prefix:DR
First Name:THARYAR
Middle Name:MYATNOE
Last Name:WILM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5863 ANDREAS WAY
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29418-5201
Mailing Address - Country:US
Mailing Address - Phone:415-916-7466
Mailing Address - Fax:
Practice Address - Street 1:8995 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9116
Practice Address - Country:US
Practice Address - Phone:415-916-7466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-05
Last Update Date:2024-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC60389183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist