Provider Demographics
NPI:1073780623
Name:SOUTH CHURCH HEALTH MART PHARMACY LLC
Entity Type:Organization
Organization Name:SOUTH CHURCH HEALTH MART PHARMACY LLC
Other - Org Name:SOUTH CHURCH HEALTH MART PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DIANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:PHRMD
Authorized Official - Phone:864-641-5351
Mailing Address - Street 1:550 S CHURCH ST
Mailing Address - Street 2:UNIT #9
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29306-3306
Mailing Address - Country:US
Mailing Address - Phone:864-596-4501
Mailing Address - Fax:864-596-4503
Practice Address - Street 1:550 S CHURCH ST
Practice Address - Street 2:UNIT #9
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29306-3306
Practice Address - Country:US
Practice Address - Phone:864-596-4501
Practice Address - Fax:864-596-4503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-13
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
SC102463336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4227751OtherNCPDP PROVIDER IDENTIFICATION NUMBER