Provider Demographics
NPI:1043679434
Name:RICKS CAROLINA PHARMACY LLC
Entity Type:Organization
Organization Name:RICKS CAROLINA PHARMACY LLC
Other - Org Name:RICK'S CAROLINA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:ADAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-784-2390
Mailing Address - Street 1:PO BOX 425
Mailing Address - Street 2:
Mailing Address - City:HARDEEVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29927-0425
Mailing Address - Country:US
Mailing Address - Phone:843-784-2390
Mailing Address - Fax:
Practice Address - Street 1:22546 WHYTE HARDEE BLVD
Practice Address - Street 2:
Practice Address - City:HARDEEVILLE
Practice Address - State:SC
Practice Address - Zip Code:29927-5738
Practice Address - Country:US
Practice Address - Phone:843-784-2390
Practice Address - Fax:843-784-2391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-15
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
SC163703336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC716370Medicaid
2158571OtherPK
GA003176788AMedicaid
7565310001Medicare NSC