Provider Demographics
NPI:1053626895
Name:SMITH, JERRY CALVIN (RPH)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:CALVIN
Last Name:SMITH
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 1:2422 WADE HAMPTON BLVD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-1146
Mailing Address - Country:US
Mailing Address - Phone:864-244-8066
Mailing Address - Fax:864-244-5443
Practice Address - Street 1:2422 WADE HAMPTON BLVD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-1146
Practice Address - Country:US
Practice Address - Phone:864-244-8066
Practice Address - Fax:864-244-5443
Is Sole Proprietor?:No
Enumeration Date:2010-08-17
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4162183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist