Provider Demographics
NPI:1063456374
Name:SC DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL
Entity Type:Organization
Organization Name:SC DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL
Other - Org Name:DHEC CENTRAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADAP DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SONYA
Authorized Official - Middle Name:
Authorized Official - Last Name:BAYONE
Authorized Official - Suffix:
Authorized Official - Credentials:MHS
Authorized Official - Phone:803-898-0829
Mailing Address - Street 1:PO BOX 809
Mailing Address - Street 2:
Mailing Address - City:STATE PARK
Mailing Address - State:SC
Mailing Address - Zip Code:29147-0809
Mailing Address - Country:US
Mailing Address - Phone:803-896-6250
Mailing Address - Fax:803-896-6252
Practice Address - Street 1:8500 FARROW RD
Practice Address - Street 2:BLDG 16
Practice Address - City:STATE PARK
Practice Address - State:SC
Practice Address - Zip Code:29147
Practice Address - Country:US
Practice Address - Phone:803-896-6250
Practice Address - Fax:803-896-6252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
SC500029863336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2092196OtherPK
SC750001Medicaid