Provider Demographics
NPI:1730362195
Name:SPARKS, ELIZABETH
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:SPARKS
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 1:200 RUTLEDGE AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29403-5848
Mailing Address - Country:US
Mailing Address - Phone:843-779-3690
Mailing Address - Fax:843-779-3691
Practice Address - Street 1:200 RUTLEDGE AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29403-5848
Practice Address - Country:US
Practice Address - Phone:843-779-3690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-08
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051170183500000X
NJ28RI02954100183500000X
SC35649183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist