Provider Demographics
NPI:1255689154
Name:PEACOCK, CLARENCE EDSEL (RPH)
Entity type:Individual
Prefix:
First Name:CLARENCE
Middle Name:EDSEL
Last Name:PEACOCK
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 1:101 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:LYMAN
Mailing Address - State:SC
Mailing Address - Zip Code:29365-1503
Mailing Address - Country:US
Mailing Address - Phone:864-439-1040
Mailing Address - Fax:864-949-0461
Practice Address - Street 1:101 LOCUST ST
Practice Address - Street 2:
Practice Address - City:LYMAN
Practice Address - State:SC
Practice Address - Zip Code:29365-1503
Practice Address - Country:US
Practice Address - Phone:864-439-1040
Practice Address - Fax:864-949-0461
Is Sole Proprietor?:No
Enumeration Date:2012-08-27
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3631183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC3631OtherSOUTH CAROLINA LICENSE #3631