1376968867 NPI number — CAROLINA PODIATRIC MEDICAL ASSOCIATES, PA COMPOUND PHARMACY

Table of content: (NPI 1376968867)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376968867 NPI number — CAROLINA PODIATRIC MEDICAL ASSOCIATES, PA COMPOUND PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAROLINA PODIATRIC MEDICAL ASSOCIATES, PA COMPOUND PHARMACY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CPMA COMPOUND PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376968867
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/16/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
721 RICHLAND AVE W
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
AIKEN
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29801-2438
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-329-2145
Provider Business Mailing Address Fax Number:
803-649-3848

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
721 RICHLAND AVE W
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
AIKEN
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29801-2438
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-329-2145
Provider Business Practice Location Address Fax Number:
803-649-3848
Provider Enumeration Date:
02/20/2014

Additional Information

Authorized Official

Authorized Official Last Name:
WALKER
Authorized Official First Name:
MACKIE
Authorized Official Middle Name:
JAMES
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
803-292-1452

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  59 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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