1699229757 NPI number — OAKRIDGE COMMUNITY CARE HOME INC

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 1699229757 NPI number — OAKRIDGE COMMUNITY CARE HOME INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OAKRIDGE COMMUNITY CARE HOME INC
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:
OAKRIDGE CARE 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:
1699229757
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/07/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2470 OLD MILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INMAN
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29349-9276
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-621-4958
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2470 OLD MILL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INMAN
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29349-9276
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-708-3477
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/06/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MAST
Authorized Official First Name:
DARRYL
Authorized Official Middle Name:
ALAN
Authorized Official Title or Position:
PHARMACIST
Authorized Official Telephone Number:
864-708-3477

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 717512 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".