Provider Demographics
NPI:1164589289
Name:PIGGLY WIGGLY OF LAMAR LLC
Entity Type:Organization
Organization Name:PIGGLY WIGGLY OF LAMAR LLC
Other - Org Name:PIGGLY WIGGLY PHARMACY #196
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:GINGER
Authorized Official - Middle Name:
Authorized Official - Last Name:DAIL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:843-326-5231
Mailing Address - Street 1:100 N RAILROAD AVE
Mailing Address - Street 2:
Mailing Address - City:LAMAR
Mailing Address - State:SC
Mailing Address - Zip Code:29069-9726
Mailing Address - Country:US
Mailing Address - Phone:843-326-5231
Mailing Address - Fax:843-326-5068
Practice Address - Street 1:100 N RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:LAMAR
Practice Address - State:SC
Practice Address - Zip Code:29069-9726
Practice Address - Country:US
Practice Address - Phone:843-326-5231
Practice Address - Fax:843-326-5068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
SC154653336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2152740OtherPK
SC741037Medicaid