Provider Demographics
NPI:1265092720
Name:COFFMAN, ROBERT L JR
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
Last Name:COFFMAN
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2647 OPHELIA WAY
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-6788
Mailing Address - Country:US
Mailing Address - Phone:843-293-0577
Mailing Address - Fax:
Practice Address - Street 1:2709 CHURCH ST STE A
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-4440
Practice Address - Country:US
Practice Address - Phone:843-365-0301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-17
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC41934183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC41934OtherREGISTERED PHARMACIST LICENCE
PARP037337LOtherREGISTERED PHARMACIST LICENCE