Provider Demographics
NPI:1114063773
Name:WYLIE, ROBERT KEELS
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:KEELS
Last Name:WYLIE
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 1:741 GRANT LAKES CIRCLE
Mailing Address - Street 2:P O BOX 505
Mailing Address - City:CHESTER
Mailing Address - State:SC
Mailing Address - Zip Code:29706
Mailing Address - Country:US
Mailing Address - Phone:803-581-7054
Mailing Address - Fax:
Practice Address - Street 1:121 CHURCH ST
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:SC
Practice Address - Zip Code:29706-2903
Practice Address - Country:US
Practice Address - Phone:803-581-2102
Practice Address - Fax:803-581-2121
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5417183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist