Provider Demographics
NPI:1245887405
Name:BRUCHON, AMY
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:BRUCHON
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 1:1870 HIGHWAY 55 W
Mailing Address - Street 2:
Mailing Address - City:CLOVER
Mailing Address - State:SC
Mailing Address - Zip Code:29710-7425
Mailing Address - Country:US
Mailing Address - Phone:864-593-0059
Mailing Address - Fax:
Practice Address - Street 1:2707 CELANESE RD
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-9406
Practice Address - Country:US
Practice Address - Phone:803-366-4157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-22
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC28919183500000X
SC42009183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist