Provider Demographics
NPI:1275030645
Name:LONGS DRUGSTORES OF SC INC
Entity Type:Organization
Organization Name:LONGS DRUGSTORES OF SC INC
Other - Org Name:AVITA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORPORATE COUNSEL/AO
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-641-7967
Mailing Address - Street 1:10604 COURSEY BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816
Mailing Address - Country:US
Mailing Address - Phone:225-236-1541
Mailing Address - Fax:225-663-2158
Practice Address - Street 1:455 LAKESHORE PKWY
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29730-4205
Practice Address - Country:US
Practice Address - Phone:803-992-3263
Practice Address - Fax:844-641-3263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-11
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
SC178123336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2177212OtherPK
SC717812Medicaid