Provider Demographics
NPI:1477698447
Name:PHILLIPS, ERNEST EUGENE
Entity Type:Individual
Prefix:MR
First Name:ERNEST
Middle Name:EUGENE
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:
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 37
Mailing Address - Street 2:
Mailing Address - City:SUMMERTON
Mailing Address - State:SC
Mailing Address - Zip Code:29148
Mailing Address - Country:US
Mailing Address - Phone:803-485-8725
Mailing Address - Fax:803-485-4306
Practice Address - Street 1:115 MAIN STREET
Practice Address - Street 2:
Practice Address - City:SUMMERTON
Practice Address - State:SC
Practice Address - Zip Code:29148
Practice Address - Country:US
Practice Address - Phone:803-485-8725
Practice Address - Fax:803-485-4306
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC004303183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC719399Medicaid
1891770574Medicare UPIN
SC719399Medicaid