Provider Demographics
NPI:1912241118
Name:PUCKETT, ERIC CONRAD (RPH)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:CONRAD
Last Name:PUCKETT
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 1:7655 KINGSTREE HWY
Mailing Address - Street 2:
Mailing Address - City:MANNING
Mailing Address - State:SC
Mailing Address - Zip Code:29102-7477
Mailing Address - Country:US
Mailing Address - Phone:803-460-8877
Mailing Address - Fax:
Practice Address - Street 1:3203 W PALMETTO ST
Practice Address - Street 2:SUITE G
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-5900
Practice Address - Country:US
Practice Address - Phone:800-849-0620
Practice Address - Fax:800-849-0622
Is Sole Proprietor?:No
Enumeration Date:2012-11-12
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC008254183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist