Provider Demographics
NPI:1912205303
Name:WILLIS, VIRGINIA A (RPH)
Entity Type:Individual
Prefix:MS
First Name:VIRGINIA
Middle Name:A
Last Name:WILLIS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:661 CLEARVIEW DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-4508
Mailing Address - Country:US
Mailing Address - Phone:843-406-0294
Mailing Address - Fax:
Practice Address - Street 1:915 FOLLY RD # A
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29412-3907
Practice Address - Country:US
Practice Address - Phone:843-795-5452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-09
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC008295183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist