Provider Demographics
NPI:1255688131
Name:WADE, JOHN BROWNING
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:BROWNING
Last Name:WADE
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 1:148 WALNUT LN
Mailing Address - Street 2:
Mailing Address - City:TRAVELERS REST
Mailing Address - State:SC
Mailing Address - Zip Code:29690-1600
Mailing Address - Country:US
Mailing Address - Phone:864-834-5327
Mailing Address - Fax:864-834-0454
Practice Address - Street 1:148 WALNUT LN
Practice Address - Street 2:
Practice Address - City:TRAVELERS REST
Practice Address - State:SC
Practice Address - Zip Code:29690-1600
Practice Address - Country:US
Practice Address - Phone:864-834-5327
Practice Address - Fax:864-834-0454
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-09
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5436183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist