Provider Demographics
NPI:1265957476
Name:ROTHROCK, BRANDON LEE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:LEE
Last Name:ROTHROCK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 PEARL ST
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29527-5719
Mailing Address - Country:US
Mailing Address - Phone:843-315-5618
Mailing Address - Fax:
Practice Address - Street 1:1303 38TH AVE N
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-1315
Practice Address - Country:US
Practice Address - Phone:843-448-4437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-08
Last Update Date:2017-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC37310183500000X
SC3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy