Provider Demographics
NPI:1083823694
Name:BUTLER, FRED DAVID
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:DAVID
Last Name:BUTLER
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 1:106 LAND STONE CIR
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-9260
Mailing Address - Country:US
Mailing Address - Phone:803-749-1374
Mailing Address - Fax:803-749-1374
Practice Address - Street 1:1010 OLD BARNWELL RD
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29170-3406
Practice Address - Country:US
Practice Address - Phone:803-358-0612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC004247183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist