Provider Demographics
NPI:1245755834
Name:FUENTES, EVER JACK (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:EVER
Middle Name:JACK
Last Name:FUENTES
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 NE MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-2010
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:930 NE MAIN ST
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681-2010
Practice Address - Country:US
Practice Address - Phone:864-963-2573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-04
Last Update Date:2017-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC37295183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist