Provider Demographics
NPI:1013265651
Name:PORTER, GERRY MELTON (RPH)
Entity Type:Individual
Prefix:
First Name:GERRY
Middle Name:MELTON
Last Name:PORTER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 SYCAMORE AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-6774
Mailing Address - Country:US
Mailing Address - Phone:843-571-4464
Mailing Address - Fax:843-769-0443
Practice Address - Street 1:65 SYCAMORE AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-6774
Practice Address - Country:US
Practice Address - Phone:843-571-4464
Practice Address - Fax:843-769-0443
Is Sole Proprietor?:No
Enumeration Date:2012-08-28
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5979183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist