Provider Demographics
NPI:1407370588
Name:CHASSEREAU, VICKI LYNN
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:LYNN
Last Name:CHASSEREAU
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 1:181 W CAROLINA AVE
Mailing Address - Street 2:
Mailing Address - City:VARNVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29944-4748
Mailing Address - Country:US
Mailing Address - Phone:803-943-2136
Mailing Address - Fax:803-943-2394
Practice Address - Street 1:181 W CAROLINA AVE
Practice Address - Street 2:
Practice Address - City:VARNVILLE
Practice Address - State:SC
Practice Address - Zip Code:29944-4748
Practice Address - Country:US
Practice Address - Phone:803-943-2136
Practice Address - Fax:803-943-2394
Is Sole Proprietor?:No
Enumeration Date:2017-07-31
Last Update Date:2017-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8670183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist