1114031564 NPI number — PRISMA HEALTH-MIDLANDS

Table of content: DR. KYLIE MICHELLE WEAVER PHARMD (NPI 1780238923)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114031564 NPI number — PRISMA HEALTH-MIDLANDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRISMA HEALTH-MIDLANDS
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:
1114031564
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/14/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7275
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29202-7275
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-296-3100
Provider Business Mailing Address Fax Number:
803-296-3319

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1400 PICKENS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29201-3465
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-296-3100
Provider Business Practice Location Address Fax Number:
803-296-3319
Provider Enumeration Date:
08/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MILLER
Authorized Official First Name:
POLLY
Authorized Official Middle Name:
H
Authorized Official Title or Position:
VP PAYOR STRATEGIES ALIGNMENT
Authorized Official Telephone Number:
864-522-2286

Provider Taxonomy Codes

  • Taxonomy code: 251V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: MC0014 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: EX0691 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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