Provider Demographics
NPI:1225394760
Name:BEAUFORT PHARMACY AND COMPOUNDING LLC
Entity Type:Organization
Organization Name:BEAUFORT PHARMACY AND COMPOUNDING LLC
Other - Org Name:CAROLINA PHARMACY OF THE LOWCOUNTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:843-729-5583
Mailing Address - Street 1:810 ELM ST E
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:SC
Mailing Address - Zip Code:29924-2610
Mailing Address - Country:US
Mailing Address - Phone:803-914-0318
Mailing Address - Fax:803-914-0311
Practice Address - Street 1:810 ELM ST E
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:SC
Practice Address - Zip Code:29924-2610
Practice Address - Country:US
Practice Address - Phone:803-914-0318
Practice Address - Fax:803-914-0311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-10
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC154923336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2149485OtherPK
SC715492Medicaid