1700095973 NPI number — VALUE MEDICAL SOUTHEAST PHARMACY

Table of content: (NPI 1700095973)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700095973 NPI number — VALUE MEDICAL SOUTHEAST PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VALUE MEDICAL SOUTHEAST PHARMACY
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:
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:
1700095973
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
105 KIOWA LANE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PIEDMONT
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29673
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-861-4965
Provider Business Mailing Address Fax Number:
888-448-1725

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 KIOWA LANE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PIEDMONT
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29673
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-861-4965
Provider Business Practice Location Address Fax Number:
888-448-1725
Provider Enumeration Date:
05/22/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
STEWART
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
BRETT
Authorized Official Title or Position:
PRINCIPAL
Authorized Official Telephone Number:
800-861-4965

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  50009230 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 3336M0002X , with the licence number: 08942 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 3336M0002X , with the licence number: 23857 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 4224781 . This is a "NCPDP #" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 57-009230 . This is a "BOARD OF PHARMACY PERMIT" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".