Provider Demographics
NPI:1942619663
Name:GATTISON, LATIFAH
Entity Type:Individual
Prefix:
First Name:LATIFAH
Middle Name:
Last Name:GATTISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 LAMAR HWY
Mailing Address - Street 2:
Mailing Address - City:DARLINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29532-4646
Mailing Address - Country:US
Mailing Address - Phone:843-393-1965
Mailing Address - Fax:
Practice Address - Street 1:406 LAMAR HWY
Practice Address - Street 2:
Practice Address - City:DARLINGTON
Practice Address - State:SC
Practice Address - Zip Code:29532-4646
Practice Address - Country:US
Practice Address - Phone:843-393-1965
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-06
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC35727183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist