Provider Demographics
NPI:1629851050
Name:WILLIE, ADAM
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:WILLIE
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 1:900 ASSEMBLY ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-3938
Mailing Address - Country:US
Mailing Address - Phone:803-212-7016
Mailing Address - Fax:
Practice Address - Street 1:900 ASSEMBLY ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-3938
Practice Address - Country:US
Practice Address - Phone:803-212-7016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC44044183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist