Provider Demographics
NPI:1346921657
Name:DREW, MICAH GOFORTH
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:GOFORTH
Last Name:DREW
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 1:57 MURRAH ROAD EXT
Mailing Address - Street 2:
Mailing Address - City:NORTH AUGUSTA
Mailing Address - State:SC
Mailing Address - Zip Code:29860-9304
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2820 AUGUSTA ROAD
Practice Address - Street 2:
Practice Address - City:WARRENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29851
Practice Address - Country:US
Practice Address - Phone:803-593-3411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-28
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC44007183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist