Provider Demographics
NPI:1144603622
Name:WILLIS, LARYSSA
Entity type:Individual
Prefix:
First Name:LARYSSA
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1385 CLASSIC CT UNIT 120
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-7267
Mailing Address - Country:US
Mailing Address - Phone:419-706-5227
Mailing Address - Fax:
Practice Address - Street 1:7771 PALMETTO COMMERCE PKWY
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29420-8825
Practice Address - Country:US
Practice Address - Phone:843-876-7074
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-02
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC36102183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist