Provider Demographics
NPI:1235140807
Name:PELHAM ROAD PHARMACY INC
Entity Type:Organization
Organization Name:PELHAM ROAD PHARMACY INC
Other - Org Name:PELHAM ROAD PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:SAMIR
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:864-234-5890
Mailing Address - Street 1:800B PELHAM RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-3300
Mailing Address - Country:US
Mailing Address - Phone:864-234-5890
Mailing Address - Fax:864-234-5891
Practice Address - Street 1:800B PELHAM RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3300
Practice Address - Country:US
Practice Address - Phone:864-234-5890
Practice Address - Fax:864-234-5891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
SC20403336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC720401Medicaid
2089695OtherPK