Provider Demographics
NPI:1326597873
Name:FURTICK, DYLAN MITCHELL
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:MITCHELL
Last Name:FURTICK
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 1:404 N ADAIR ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:SC
Mailing Address - Zip Code:29325-2408
Mailing Address - Country:US
Mailing Address - Phone:803-300-4294
Mailing Address - Fax:
Practice Address - Street 1:518 E GREER ST
Practice Address - Street 2:
Practice Address - City:HONEA PATH
Practice Address - State:SC
Practice Address - Zip Code:29654-1823
Practice Address - Country:US
Practice Address - Phone:864-369-0707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-26
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC36832183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist