Provider Demographics
NPI:1285190900
Name:CORBETT, ANGELIQUE MARIE (CPHT)
Entity Type:Individual
Prefix:
First Name:ANGELIQUE
Middle Name:MARIE
Last Name:CORBETT
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 GEORGE BISHOP PKWY
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-7335
Mailing Address - Country:US
Mailing Address - Phone:843-903-6212
Mailing Address - Fax:843-903-5432
Practice Address - Street 1:104 GEORGE BISHOP PKWY
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-7335
Practice Address - Country:US
Practice Address - Phone:843-903-6212
Practice Address - Fax:843-903-5432
Is Sole Proprietor?:No
Enumeration Date:2019-02-19
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC15226183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician