Provider Demographics
NPI:1730439126
Name:WILLIAMSON, O'STACIA
Entity type:Individual
Prefix:
First Name:O'STACIA
Middle Name:
Last Name:WILLIAMSON
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 1:2004 CRIPPLECREEK DR
Mailing Address - Street 2:
Mailing Address - City:LADSON
Mailing Address - State:SC
Mailing Address - Zip Code:29456
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1316 REDBANK RD
Practice Address - Street 2:9
Practice Address - City:GOOSE CREEK
Practice Address - State:SC
Practice Address - Zip Code:29445
Practice Address - Country:US
Practice Address - Phone:843-572-5707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11892183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist