Provider Demographics
NPI:1871550897
Name:POOLE, BENJAMIN C (OD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:C
Last Name:POOLE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 BETHEL ST
Mailing Address - Street 2:
Mailing Address - City:CLOVER
Mailing Address - State:SC
Mailing Address - Zip Code:29710-1101
Mailing Address - Country:US
Mailing Address - Phone:803-222-9538
Mailing Address - Fax:803-222-1898
Practice Address - Street 1:121 BETHEL ST
Practice Address - Street 2:
Practice Address - City:CLOVER
Practice Address - State:SC
Practice Address - Zip Code:29710-1101
Practice Address - Country:US
Practice Address - Phone:803-222-9538
Practice Address - Fax:803-222-1898
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC1109152W00000X
SCSC 728152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD07286Medicaid
SC570788101001OtherBCBS OF SC
NC09655OtherBCBS OF NC
NC89-09655Medicaid
NC09655OtherBCBS OF NC
SCD07286Medicaid
SC570788101001OtherBCBS OF SC
NC89-09655Medicaid