1780958744 NPI number — DOGWOOD PHARMACY, LLC

Table of content: (NPI 1780958744)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780958744 NPI number — DOGWOOD PHARMACY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DOGWOOD 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:
6
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:
1780958744
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1325 MILLER RD, SUITE K
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29607-6541
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-840-4067
Provider Business Mailing Address Fax Number:
866-514-8299

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1325 MILLER RD, SUITE K
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29607-6541
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-840-4067
Provider Business Practice Location Address Fax Number:
866-514-8299
Provider Enumeration Date:
03/08/2012

Additional Information

Authorized Official

Authorized Official Last Name:
MONTANEZ
Authorized Official First Name:
ELVIN
Authorized Official Middle Name:
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
800-628-6965

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336H0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 13938 , 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: 1780953744 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2134795 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 713938 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003124413A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 012563400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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