Provider Demographics
NPI:1780294876
Name:FAZIO, HANNAH GREEN (PHARMD)
Entity type:Individual
Prefix:
First Name:HANNAH
Middle Name:GREEN
Last Name:FAZIO
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 1:131 RIVERDALE RD
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29680-7745
Mailing Address - Country:US
Mailing Address - Phone:803-981-2887
Mailing Address - Fax:
Practice Address - Street 1:694 FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29680-6708
Practice Address - Country:US
Practice Address - Phone:864-963-4406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-04
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC42611183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC42611OtherSOUTH CAROLINE BOARD OF PHARMACY