Provider Demographics
NPI:1700209905
Name:WYATT, ROBERT W
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:WYATT
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 1:203 CEDAR SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29302-4639
Mailing Address - Country:US
Mailing Address - Phone:864-381-6366
Mailing Address - Fax:864-381-6367
Practice Address - Street 1:203 CEDAR SPRINGS RD
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29302
Practice Address - Country:US
Practice Address - Phone:864-381-6366
Practice Address - Fax:864-381-6367
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-24
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5949183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC5949OtherSC LIC PHARMACIST