Provider Demographics
NPI:1871122440
Name:COLVIN, NATASHA NICOLETTE
Entity type:Individual
Prefix:
First Name:NATASHA
Middle Name:NICOLETTE
Last Name:COLVIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 CHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:SC
Mailing Address - Zip Code:29055-8871
Mailing Address - Country:US
Mailing Address - Phone:803-209-5725
Mailing Address - Fax:
Practice Address - Street 1:422 N FRASER ST
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29440-3260
Practice Address - Country:US
Practice Address - Phone:843-904-9257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-06
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC37051183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC37051OtherBOARD OF PHARMACY LICENSE