Provider Demographics
NPI:1538629209
Name:GARDNER, PHILLIP REID
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:REID
Last Name:GARDNER
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 1:107 KNOX ABBOTT DR UNIT 1304
Mailing Address - Street 2:
Mailing Address - City:CAYCE
Mailing Address - State:SC
Mailing Address - Zip Code:29033-4406
Mailing Address - Country:US
Mailing Address - Phone:704-913-3364
Mailing Address - Fax:
Practice Address - Street 1:107 KNOX ABBOTT DR UNIT 1304
Practice Address - Street 2:
Practice Address - City:CAYCE
Practice Address - State:SC
Practice Address - Zip Code:29033-4406
Practice Address - Country:US
Practice Address - Phone:704-913-3364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-20
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC42168183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist