Provider Demographics
NPI:1417443029
Name:GARDO, JUSTIN LEE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:LEE
Last Name:GARDO
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 JAMES WAY APT B1
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29642-0804
Mailing Address - Country:US
Mailing Address - Phone:864-859-3400
Mailing Address - Fax:
Practice Address - Street 1:1405 E GREENVILLE ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-2049
Practice Address - Country:US
Practice Address - Phone:864-224-8797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-06
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC37653183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist