Provider Demographics
NPI:1114142528
Name:LAKE WYLIE HEALTHCARE, LLC
Entity Type:Organization
Organization Name:LAKE WYLIE HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:
Authorized Official - Last Name:TAMBERELLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-631-4466
Mailing Address - Street 1:5420 HIGHWAY 55 E
Mailing Address - Street 2:
Mailing Address - City:LAKE WYLIE
Mailing Address - State:SC
Mailing Address - Zip Code:29710-8586
Mailing Address - Country:US
Mailing Address - Phone:803-631-4466
Mailing Address - Fax:803-631-4477
Practice Address - Street 1:5420 HIGHWAY 55 E
Practice Address - Street 2:
Practice Address - City:LAKE WYLIE
Practice Address - State:SC
Practice Address - Zip Code:29710-8586
Practice Address - Country:US
Practice Address - Phone:803-631-4466
Practice Address - Fax:803-631-4477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC50007181183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty