Provider Demographics
NPI:1306242664
Name:OUELLET, DAVID
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:OUELLET
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 CORONADO DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-5409
Mailing Address - Country:US
Mailing Address - Phone:803-479-8419
Mailing Address - Fax:
Practice Address - Street 1:1002 SAMS CROSSING RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29229-9591
Practice Address - Country:US
Practice Address - Phone:803-788-0535
Practice Address - Fax:803-788-8750
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-14
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC35583183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist