Provider Demographics
NPI:1801910211
Name:WADDELL, TOMMY L (PHARMACIST)
Entity type:Individual
Prefix:
First Name:TOMMY
Middle Name:L
Last Name:WADDELL
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:244 CAROLINA DR
Mailing Address - Street 2:
Mailing Address - City:LORIS
Mailing Address - State:SC
Mailing Address - Zip Code:29569-5334
Mailing Address - Country:US
Mailing Address - Phone:843-756-1017
Mailing Address - Fax:
Practice Address - Street 1:4125 MAIN ST
Practice Address - Street 2:
Practice Address - City:LORIS
Practice Address - State:SC
Practice Address - Zip Code:29569-3023
Practice Address - Country:US
Practice Address - Phone:843-756-4021
Practice Address - Fax:843-756-9124
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC005603183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist