Provider Demographics
NPI:1164149563
Name:PALMETTO SPECIALTY PHARM LLC
Entity Type:Organization
Organization Name:PALMETTO SPECIALTY PHARM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:FENNICK
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:724-683-6779
Mailing Address - Street 1:1200 TWO ISLAND CT UNIT B
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-7418
Mailing Address - Country:US
Mailing Address - Phone:843-972-7704
Mailing Address - Fax:843-972-9395
Practice Address - Street 1:1200 TWO ISLAND CT UNIT B
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29466-7418
Practice Address - Country:US
Practice Address - Phone:843-972-7704
Practice Address - Fax:843-972-9395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-26
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC20906OtherSOUTH CAROLINA STATE PHARMACY LICENSE