1801499363 NPI number — DR. JERRY HENRY WILES III PHARMD

Table of content: DR. JERRY HENRY WILES III PHARMD (NPI 1801499363)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801499363 NPI number — DR. JERRY HENRY WILES III PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILES
Provider First Name:
JERRY
Provider Middle Name:
HENRY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
PHARMD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1801499363
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/18/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 DEVON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAULDIN
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29662-1914
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-642-7480
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
845 S BUNCOMBE RD STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREER
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29650-2432
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-522-1700
Provider Business Practice Location Address Fax Number:
864-522-1724
Provider Enumeration Date:
11/18/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  37717 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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