1770588097 NPI number — IVA DRUG STORE, INC.

Table of content: (NPI 1770588097)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770588097 NPI number — IVA DRUG STORE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IVA DRUG STORE, 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:
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:
1770588097
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/13/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
720 EAST FRONT STREET
Provider Second Line Business Mailing Address:
P.O. BOX 26
Provider Business Mailing Address City Name:
IVA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29655
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-348-6138
Provider Business Mailing Address Fax Number:
864-348-2220

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
720 E FRONT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IVA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29655-9089
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-348-6138
Provider Business Practice Location Address Fax Number:
864-348-2220
Provider Enumeration Date:
06/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BOLES
Authorized Official First Name:
LANCE
Authorized Official Middle Name:
P
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
864-348-6138

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  50008094 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 50008094 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 741128 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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