1568527752 NPI number — WALTER W ROGAN

Table of content: (NPI 1568527752)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568527752 NPI number — WALTER W ROGAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WALTER W ROGAN
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:
GREELEYVILLE 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:
1568527752
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/30/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 277
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREELEYVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29056-0277
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
215 VARNER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREELEYVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29056-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-426-2170
Provider Business Practice Location Address Fax Number:
843-426-2166
Provider Enumeration Date:
12/27/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ROGAN
Authorized Official First Name:
WALTER
Authorized Official Middle Name:
W
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
843-426-2170

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 1702 , 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)

  • Identifier: 2089102 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 717056 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".