Provider Demographics
NPI:1144528407
Name:PLATT, WANDA
Entity type:Individual
Prefix:DR
First Name:WANDA
Middle Name:
Last Name:PLATT
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 1:12845 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:SC
Mailing Address - Zip Code:29853-2711
Mailing Address - Country:US
Mailing Address - Phone:803-266-4345
Mailing Address - Fax:
Practice Address - Street 1:12845 MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:SC
Practice Address - Zip Code:29853-2711
Practice Address - Country:US
Practice Address - Phone:803-266-4345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-09
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12582183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist