Provider Demographics
NPI:1437409547
Name:PROCTOR, KARISSA MARIE (PHARMD)
Entity Type:Individual
Prefix:
First Name:KARISSA
Middle Name:MARIE
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1610 CHURCH ST STE U
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-2932
Mailing Address - Country:US
Mailing Address - Phone:843-248-0505
Mailing Address - Fax:843-381-0961
Practice Address - Street 1:1610 CHURCH ST STE U
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-2932
Practice Address - Country:US
Practice Address - Phone:843-248-0505
Practice Address - Fax:843-381-0961
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-17
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13151183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist