1033131602 NPI number — STROM'S DRUG STORE #2

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033131602 NPI number — STROM'S DRUG STORE #2

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STROM'S DRUG STORE #2
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:
Provider Other Organization Name Type Code:
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:
1033131602
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/05/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
124 SOUTH MAIN STREET
Provider Second Line Business Mailing Address:
P.O. BOX 1838
Provider Business Mailing Address City Name:
MC CORMICK
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29835
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-465-2011
Provider Business Mailing Address Fax Number:
864-465-3150

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
124 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCCORMICK
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29835
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-465-2011
Provider Business Practice Location Address Fax Number:
864-465-3150
Provider Enumeration Date:
07/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FLYNN
Authorized Official First Name:
ROY
Authorized Official Middle Name:
NORBERT
Authorized Official Title or Position:
VP
Authorized Official Telephone Number:
803-968-7000

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; 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: "Y" .

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

  • Identifier: 799972 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4205577 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4205577 . This is a "NCDDP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 710880 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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