Provider Demographics
NPI:1225373574
Name:FOGLE, TAVIA S (RPH)
Entity Type:Individual
Prefix:
First Name:TAVIA
Middle Name:S
Last Name:FOGLE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4633 SAVANNAH HWY
Mailing Address - Street 2:
Mailing Address - City:NORTH
Mailing Address - State:SC
Mailing Address - Zip Code:29112-8180
Mailing Address - Country:US
Mailing Address - Phone:803-247-2133
Mailing Address - Fax:803-247-3081
Practice Address - Street 1:4633 SAVANNAH HWY
Practice Address - Street 2:
Practice Address - City:NORTH
Practice Address - State:SC
Practice Address - Zip Code:29112-8180
Practice Address - Country:US
Practice Address - Phone:803-247-2133
Practice Address - Fax:803-247-3081
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-27
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8772183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist