Provider Demographics
NPI:1730538828
Name:BROADWATER, BENJAMIN (PHARMD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:BROADWATER
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 N ADAIR ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:SC
Mailing Address - Zip Code:29325-2405
Mailing Address - Country:US
Mailing Address - Phone:803-318-6395
Mailing Address - Fax:
Practice Address - Street 1:3300 WADE HAMPTON BLVD
Practice Address - Street 2:
Practice Address - City:TAYLORS
Practice Address - State:SC
Practice Address - Zip Code:29687-2902
Practice Address - Country:US
Practice Address - Phone:864-268-9160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-08
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC36463183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist