Provider Demographics
NPI:1497052666
Name:NUSSBAUM, TED TRISTAN (RPH)
Entity Type:Individual
Prefix:
First Name:TED
Middle Name:TRISTAN
Last Name:NUSSBAUM
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 1:1404 BRITISH DR
Mailing Address - Street 2:
Mailing Address - City:MONCKS CORNER
Mailing Address - State:SC
Mailing Address - Zip Code:29461-7128
Mailing Address - Country:US
Mailing Address - Phone:843-830-8640
Mailing Address - Fax:843-899-4702
Practice Address - Street 1:1008 OLD HIGHWAY 52 STE G
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-3011
Practice Address - Country:US
Practice Address - Phone:843-899-4700
Practice Address - Fax:843-899-4702
Is Sole Proprietor?:No
Enumeration Date:2011-02-23
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11560183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist