1053403964 NPI number — LONGS DRUGSTORES OF SC 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 1053403964 NPI number — LONGS DRUGSTORES OF SC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LONGS DRUGSTORES OF SC 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:
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:
1053403964
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/19/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 602688
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28260-2688
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-788-9608
Provider Business Mailing Address Fax Number:
803-788-7170

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 BLARNEY DR STE 105
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29223-6291
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-788-9608
Provider Business Practice Location Address Fax Number:
803-788-7170
Provider Enumeration Date:
09/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FROST
Authorized Official First Name:
MARSHALL
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF BUSINESS DEV
Authorized Official Telephone Number:
404-583-6945

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 15059 , 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: 2089902 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1053403964 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com