Provider Demographics
NPI:1962709147
Name:TISDALE, KAYCEE (PHARMD)
Entity type:Individual
Prefix:
First Name:KAYCEE
Middle Name:
Last Name:TISDALE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 NELSON BLVD
Mailing Address - Street 2:
Mailing Address - City:KINGSTREE
Mailing Address - State:SC
Mailing Address - Zip Code:29556-4025
Mailing Address - Country:US
Mailing Address - Phone:843-354-3373
Mailing Address - Fax:
Practice Address - Street 1:480 NELSON BLVD
Practice Address - Street 2:
Practice Address - City:KINGSTREE
Practice Address - State:SC
Practice Address - Zip Code:29556-4025
Practice Address - Country:US
Practice Address - Phone:843-354-3373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-24
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10340183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist