Provider Demographics
NPI:1730817859
Name:MINGLEDOLPH, KETURAH (PHARMD)
Entity type:Individual
Prefix:
First Name:KETURAH
Middle Name:
Last Name:MINGLEDOLPH
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4050 BROWNSTONE DR APT 910
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-9133
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4295 JEFFERSON DAVIS HWY
Practice Address - Street 2:
Practice Address - City:BEECH ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29842-4824
Practice Address - Country:US
Practice Address - Phone:803-593-5196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-09
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC43592183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist