Provider Demographics
NPI:1275819286
Name:GOTHERIDGE, CYNTHIA MARIE
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:MARIE
Last Name:GOTHERIDGE
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 1:7467 SAINT ANDREWS RD STE 6
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-2876
Mailing Address - Country:US
Mailing Address - Phone:803-732-0426
Mailing Address - Fax:803-732-2698
Practice Address - Street 1:7467 SAINT ANDREWS RD STE 6
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-2876
Practice Address - Country:US
Practice Address - Phone:803-732-0426
Practice Address - Fax:803-732-2698
Is Sole Proprietor?:No
Enumeration Date:2011-10-24
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9642183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist