Provider Demographics
NPI:1043365703
Name:SOUTH CAROLINA DEPARTMENT OF MENTAL HEALTH
Entity Type:Organization
Organization Name:SOUTH CAROLINA DEPARTMENT OF MENTAL HEALTH
Other - Org Name:C.M.TUCKER,JR NURSING CARE CENTER PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF PROFESSIONAL SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:BUTTERFLY
Authorized Official - Last Name:RUDD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-737-5301
Mailing Address - Street 1:2200 HARDEN ST.
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-7107
Mailing Address - Country:US
Mailing Address - Phone:803-737-5339
Mailing Address - Fax:803-737-5436
Practice Address - Street 1:2200 HARDEN ST.
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-7107
Practice Address - Country:US
Practice Address - Phone:803-737-5339
Practice Address - Fax:803-737-5436
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTH CAROLINA DEPARTMENT OF MENTAL HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-24
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC50001783313M00000X, 315D00000X, 332BN1400X, 333600000X, 3336L0003X
SC50-001783314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No315D00000XNursing & Custodial Care FacilitiesHospice, Inpatient
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4212875OtherNCPDP