1417582032 NPI number — BURGESS CLOSED DOOR PHARMACY LLC

Table of content: (NPI 1417582032)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417582032 NPI number — BURGESS CLOSED DOOR PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BURGESS CLOSED DOOR PHARMACY 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:
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:
1417582032
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/09/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2125 SUNSHINE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LANCASTER
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29720-9208
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-804-2700
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
615 W EVANS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLORENCE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29501-3409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-472-5066
Provider Business Practice Location Address Fax Number:
843-472-5062
Provider Enumeration Date:
03/04/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WOODARD
Authorized Official First Name:
MYEESHA
Authorized Official Middle Name:
SANTRELL
Authorized Official Title or Position:
PHARMACIST IN CHARGE
Authorized Official Telephone Number:
803-804-2700

Provider Taxonomy Codes

  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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