Provider Demographics
NPI:1316951320
Name:TODD, KERMIT RANDY (RPH)
Entity type:Individual
Prefix:PROF
First Name:KERMIT
Middle Name:RANDY
Last Name:TODD
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-3568
Mailing Address - Country:US
Mailing Address - Phone:843-248-4609
Mailing Address - Fax:
Practice Address - Street 1:1401 MAIN ST
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-3568
Practice Address - Country:US
Practice Address - Phone:843-248-4609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6624183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist