Provider Demographics
NPI:1548670508
Name:AVANT, DONNA GRANTHAM (RPH)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:GRANTHAM
Last Name:AVANT
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 309
Mailing Address - Street 2:
Mailing Address - City:EHRHARDT
Mailing Address - State:SC
Mailing Address - Zip Code:29081-0309
Mailing Address - Country:US
Mailing Address - Phone:803-267-2121
Mailing Address - Fax:803-267-2124
Practice Address - Street 1:12930 BROXTON BRIDGE RD
Practice Address - Street 2:
Practice Address - City:EHRHARDT
Practice Address - State:SC
Practice Address - Zip Code:29081-0309
Practice Address - Country:US
Practice Address - Phone:803-267-2121
Practice Address - Fax:803-267-2124
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-30
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC006565183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC7418600001Medicare NSC