Provider Demographics
NPI:1891196093
Name:FAILE, JERRY DOUGLAS
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:DOUGLAS
Last Name:FAILE
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 1:2240 W DEKALB ST
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:SC
Mailing Address - Zip Code:29020-2069
Mailing Address - Country:US
Mailing Address - Phone:803-425-4096
Mailing Address - Fax:803-425-4096
Practice Address - Street 1:2240 W DEKALB ST
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:SC
Practice Address - Zip Code:29020-2069
Practice Address - Country:US
Practice Address - Phone:803-425-4096
Practice Address - Fax:803-425-4096
Is Sole Proprietor?:No
Enumeration Date:2014-09-08
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4139183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist