Provider Demographics
NPI:1477838423
Name:JERIC, DAVID (RPH)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:JERIC
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5232 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LORIS
Mailing Address - State:SC
Mailing Address - Zip Code:29569-2656
Mailing Address - Country:US
Mailing Address - Phone:843-756-4150
Mailing Address - Fax:
Practice Address - Street 1:5001 SOCASTEE BLVD
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-7339
Practice Address - Country:US
Practice Address - Phone:843-293-6066
Practice Address - Fax:843-293-6238
Is Sole Proprietor?:No
Enumeration Date:2011-10-20
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV15809183500000X
OH03-3-18448183500000X
SC35969183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist