Provider Demographics
NPI:1336139203
Name:VINCENT, JAMES THOMAS (SR)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:THOMAS
Last Name:VINCENT
Suffix:
Gender:M
Credentials:SR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 LEE AVE
Mailing Address - Street 2:P O BOX 8
Mailing Address - City:HAMPTON
Mailing Address - State:SC
Mailing Address - Zip Code:29924-3441
Mailing Address - Country:US
Mailing Address - Phone:803-943-3521
Mailing Address - Fax:803-943-3521
Practice Address - Street 1:203 LEE AVE
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:SC
Practice Address - Zip Code:29924-3441
Practice Address - Country:US
Practice Address - Phone:803-943-3521
Practice Address - Fax:803-943-3521
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3939183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC713655Medicaid