Provider Demographics
NPI:1093319956
Name:GERALD, TIFFANY DENISE (PHARMD)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:DENISE
Last Name:GERALD
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 1:1827 ROAD 30
Mailing Address - Street 2:
Mailing Address - City:LAKE VIEW
Mailing Address - State:SC
Mailing Address - Zip Code:29563-5215
Mailing Address - Country:US
Mailing Address - Phone:267-382-8435
Mailing Address - Fax:
Practice Address - Street 1:707 CHURCH ST
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-4824
Practice Address - Country:US
Practice Address - Phone:843-248-6302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-22
Last Update Date:2020-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC42760183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPH42760OtherLICENSE