1942205950 NPI number — PALMETTO PHARMACY ENTERPRISES LLC

Table of content: (NPI 1942205950)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942205950 NPI number — PALMETTO PHARMACY ENTERPRISES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PALMETTO PHARMACY ENTERPRISES LLC
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:
PALMETTO PHARMACY ENTERPRISES LLC
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:
1942205950
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 853
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAMPTON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29924-0853
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:
810 ELM ST E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAMPTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29924-2610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-943-9327
Provider Business Practice Location Address Fax Number:
803-943-9329
Provider Enumeration Date:
06/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
HARDISON
Authorized Official First Name:
RHONDA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
803-943-9327

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 50007543 , 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: 775431 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4225240 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: DE2489 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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