Provider Demographics
NPI:1194181669
Name:BASHAM, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:BASHAM
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 1:2219 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-3340
Mailing Address - Country:US
Mailing Address - Phone:843-488-4400
Mailing Address - Fax:843-488-4405
Practice Address - Street 1:2219 MAIN ST
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-3340
Practice Address - Country:US
Practice Address - Phone:843-488-4400
Practice Address - Fax:843-488-4405
Is Sole Proprietor?:No
Enumeration Date:2016-01-13
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9657183500000X
KY011627183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist