Provider Demographics
NPI:1053482893
Name:ELAM, MARIE ANNETTE
Entity type:Individual
Prefix:MRS
First Name:MARIE
Middle Name:ANNETTE
Last Name:ELAM
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 1:4 YARDLEY CT
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-4467
Mailing Address - Country:US
Mailing Address - Phone:864-967-7527
Mailing Address - Fax:864-476-6012
Practice Address - Street 1:345 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WOODRUFF
Practice Address - State:SC
Practice Address - Zip Code:29388-1867
Practice Address - Country:US
Practice Address - Phone:864-476-2111
Practice Address - Fax:864-476-6012
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10303183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist