Provider Demographics
NPI:1174246110
Name:WIMBISH, MADISON NICOLE
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:NICOLE
Last Name:WIMBISH
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 1:11920 HIGHWAY 707 STE A
Mailing Address - Street 2:
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576-9609
Mailing Address - Country:US
Mailing Address - Phone:843-353-5614
Mailing Address - Fax:
Practice Address - Street 1:11920 HIGHWAY 707 STE A
Practice Address - Street 2:
Practice Address - City:MURRELLS INLET
Practice Address - State:SC
Practice Address - Zip Code:29576-9609
Practice Address - Country:US
Practice Address - Phone:843-353-5614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-23
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC60010183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician