1598758955 NPI number — PROFESSIONAL PHARMACY SERVICES, INC

Table of content: (NPI 1598758955)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598758955 NPI number — PROFESSIONAL PHARMACY SERVICES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL PHARMACY SERVICES, 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:
1598758955
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7487
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLORENCE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29502-7487
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-665-4051
Provider Business Mailing Address Fax Number:
843-799-2493

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
773 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH MYRTLE BEACH
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29582-3029
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-665-4051
Provider Business Practice Location Address Fax Number:
843-799-2493
Provider Enumeration Date:
08/31/2005

Additional Information

Authorized Official

Authorized Official Last Name:
STURGEON
Authorized Official First Name:
JONATHAN
Authorized Official Middle Name:
KYLE
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
843-665-4051

Provider Taxonomy Codes

  • Taxonomy code: 332BP3500X , with the licence number:  50-006977 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BX2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 769771 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: DME-197 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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