1649250333 NPI number — HEDGEMARK BRENTWOOD PHARMACY, INC.

Table of content: (NPI 1649250333)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649250333 NPI number — HEDGEMARK BRENTWOOD PHARMACY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEDGEMARK BRENTWOOD PHARMACY, 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:
PHARMACEUTICAL HEALTH CARE
Provider Other Organization Name Type Code:
3
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:
1649250333
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1548 ASHLEY RIVER ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLESTON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29407
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-762-1177
Provider Business Mailing Address Fax Number:
843-762-4506

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1548 ASHLEY RIVER ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-762-1177
Provider Business Practice Location Address Fax Number:
843-762-4506
Provider Enumeration Date:
01/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DURRENCE
Authorized Official First Name:
ELLEN
Authorized Official Middle Name:
S.
Authorized Official Title or Position:
V-PRESIDENT
Authorized Official Telephone Number:
843-762-1177

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332BC3200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BP3500X ; 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: "N" .
  • Taxonomy code: 333600000X , with the licence number: 50-002227 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 561663 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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