1659360873 NPI number — MCLEOD HEALTH CLARENDON LTC PHARMACY

Table of content: (NPI 1659360873)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659360873 NPI number — MCLEOD HEALTH CLARENDON LTC PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MCLEOD HEALTH CLARENDON LTC 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:
CYPRESS CENTER LTC PHARMACY
Provider Other Organization Name Type Code:
4
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:
1659360873
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/25/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
50 E HOSPITAL ST
Provider Second Line Business Mailing Address:
STE 1B
Provider Business Mailing Address City Name:
MANNING
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29102-3149
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-435-5272
Provider Business Mailing Address Fax Number:
803-435-5271

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
50 E HOSPITAL ST
Provider Second Line Business Practice Location Address:
STE 1B
Provider Business Practice Location Address City Name:
MANNING
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29102-3149
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-435-5272
Provider Business Practice Location Address Fax Number:
803-435-5271
Provider Enumeration Date:
10/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
ERVIN
Authorized Official First Name:
SAMUEL
Authorized Official Middle Name:
FULTON
Authorized Official Title or Position:
SR VP AND CFO
Authorized Official Telephone Number:
843-777-2910

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  16726 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 722205 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2163851 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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