1598438582 NPI number — PEACH VALLEY PHARMACY, LLC

Table of content: (NPI 1598438582)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598438582 NPI number — PEACH VALLEY PHARMACY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEACH VALLEY 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:
1598438582
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 72148
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBANY
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31708-2148
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-435-4571
Provider Business Mailing Address Fax Number:
229-435-7069

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2310 CHESNEE HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPARTANBURG
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29303-5505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-577-0087
Provider Business Practice Location Address Fax Number:
884-577-0599
Provider Enumeration Date:
07/27/2021

Additional Information

Authorized Official

Authorized Official Last Name:
MOODY
Authorized Official First Name:
BEVERLY
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
229-435-4571

Provider Taxonomy Codes

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

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

  • Identifier: 714209 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com