Provider Demographics
NPI:1942664669
Name:SMITH, STACEY K (RPH)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:K
Last Name:SMITH
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:STACEY
Other - Last Name:KERWIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:330 HAMMOND DR
Mailing Address - Street 2:
Mailing Address - City:ALLENDALE
Mailing Address - State:SC
Mailing Address - Zip Code:29810-2122
Mailing Address - Country:US
Mailing Address - Phone:803-584-0823
Mailing Address - Fax:
Practice Address - Street 1:1787 ALLENDALE FAIRFAX HWY
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:SC
Practice Address - Zip Code:29827-9133
Practice Address - Country:US
Practice Address - Phone:803-702-4279
Practice Address - Fax:803-632-8164
Is Sole Proprietor?:No
Enumeration Date:2016-04-08
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8721183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC8721OtherSC LLR BOARD OF PHARMACY