Provider Demographics
NPI:1669779682
Name:PUCKETT-BEASLEY, JESSICA (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:
Last Name:PUCKETT-BEASLEY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1116 SILVER POINT RD
Mailing Address - Street 2:
Mailing Address - City:CHAPIN
Mailing Address - State:SC
Mailing Address - Zip Code:29036-7903
Mailing Address - Country:US
Mailing Address - Phone:843-860-4493
Mailing Address - Fax:
Practice Address - Street 1:107 WESTPARK BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210-3871
Practice Address - Country:US
Practice Address - Phone:803-772-4809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-28
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10477183500000X
GA018810183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist