Provider Demographics
NPI:1033118757
Name:COMMUNITY PHARMACY OF CHESTER LLC
Entity Type:Organization
Organization Name:COMMUNITY PHARMACY OF CHESTER LLC
Other - Org Name:BLACKS DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:RICHARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-904-3287
Mailing Address - Street 1:PO BOX 578
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:SC
Mailing Address - Zip Code:29706-0578
Mailing Address - Country:US
Mailing Address - Phone:803-581-2102
Mailing Address - Fax:803-581-2121
Practice Address - Street 1:121 CHURCH ST
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:SC
Practice Address - Zip Code:29706-2903
Practice Address - Country:US
Practice Address - Phone:803-581-2102
Practice Address - Fax:803-581-2121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-15
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0003X
SC65743336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2090205OtherPK
SC718772Medicaid
0167570001Medicare NSC