Provider Demographics
NPI:1992124259
Name:TANNER, BOBBY
Entity type:Individual
Prefix:
First Name:BOBBY
Middle Name:
Last Name:TANNER
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 1:486 GREENVIEW DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29555-6605
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:305 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:MULLINS
Practice Address - State:SC
Practice Address - Zip Code:29574-6241
Practice Address - Country:US
Practice Address - Phone:843-423-7510
Practice Address - Fax:843-423-9242
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-15
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8580183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist