Provider Demographics
NPI:1457462624
Name:DYCHES, THERESA KRAFNICK (RPH)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:KRAFNICK
Last Name:DYCHES
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:WAGENER
Mailing Address - State:SC
Mailing Address - Zip Code:29164-0129
Mailing Address - Country:US
Mailing Address - Phone:803-564-5381
Mailing Address - Fax:803-564-5398
Practice Address - Street 1:129 NORTH MAIN ST
Practice Address - Street 2:
Practice Address - City:WAGENER
Practice Address - State:SC
Practice Address - Zip Code:29164-0129
Practice Address - Country:US
Practice Address - Phone:803-564-5381
Practice Address - Fax:803-564-5398
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8488183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDME1001Medicaid
SC1114270001Medicare ID - Type Unspecified