Provider Demographics
NPI:1336693001
Name:MITCHELL, SIDRA
Entity Type:Individual
Prefix:
First Name:SIDRA
Middle Name:
Last Name:MITCHELL
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 1:5119 SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-9155
Mailing Address - Country:US
Mailing Address - Phone:803-520-2859
Mailing Address - Fax:803-358-8575
Practice Address - Street 1:5119 SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-9155
Practice Address - Country:US
Practice Address - Phone:803-520-2859
Practice Address - Fax:803-358-8575
Is Sole Proprietor?:No
Enumeration Date:2016-08-10
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC36758183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist