Provider Demographics
NPI:1073385787
Name:MADE, JONATHAN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:MADE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2410 CHARLESTON HWY
Mailing Address - Street 2:
Mailing Address - City:CAYCE
Mailing Address - State:SC
Mailing Address - Zip Code:29033-1736
Mailing Address - Country:US
Mailing Address - Phone:803-796-2586
Mailing Address - Fax:
Practice Address - Street 1:2410 CHARLESTON HWY
Practice Address - Street 2:
Practice Address - City:CAYCE
Practice Address - State:SC
Practice Address - Zip Code:29033-1736
Practice Address - Country:US
Practice Address - Phone:321-945-0541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-25
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC44152183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist