Provider Demographics
NPI:1215541800
Name:CANTY, CANDACE LATESSE
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:LATESSE
Last Name:CANTY
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 1:510 DOGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BISHOPVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29010-1914
Mailing Address - Country:US
Mailing Address - Phone:803-795-3398
Mailing Address - Fax:
Practice Address - Street 1:1080 ALICE DR
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-2463
Practice Address - Country:US
Practice Address - Phone:803-778-0460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC42669183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist