Provider Demographics
NPI:1689285033
Name:ARDIS, BREANNA DANIELLE (PHARMD)
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:DANIELLE
Last Name:ARDIS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2418 AUGUSTA HWY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-2216
Mailing Address - Country:US
Mailing Address - Phone:803-358-8210
Mailing Address - Fax:
Practice Address - Street 1:2418 AUGUSTA HWY
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-2216
Practice Address - Country:US
Practice Address - Phone:803-358-8210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-10
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC42598183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist