Provider Demographics
NPI:1164767729
Name:FALLAW, BRETT C
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:C
Last Name:FALLAW
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 1:1000 JOHNNIE DODDS BLVD
Mailing Address - Street 2:PUBLIX PHARMACY
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-3135
Mailing Address - Country:US
Mailing Address - Phone:843-856-3007
Mailing Address - Fax:843-856-3014
Practice Address - Street 1:1000 JOHNNIE DODDS BLVD STE 106
Practice Address - Street 2:PUBLIX PHARMACY
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3187
Practice Address - Country:US
Practice Address - Phone:843-856-3007
Practice Address - Fax:843-856-3014
Is Sole Proprietor?:No
Enumeration Date:2012-12-06
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC009698183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist