Provider Demographics
NPI:1275612269
Name:WATEREE PLAZA DRUG CORP
Entity Type:Organization
Organization Name:WATEREE PLAZA DRUG CORP
Other - Org Name:LIGGETT COMPOUNDING PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:F
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:803-438-8234
Mailing Address - Street 1:PO BOX 236
Mailing Address - Street 2:
Mailing Address - City:LUGOFF
Mailing Address - State:SC
Mailing Address - Zip Code:29078
Mailing Address - Country:US
Mailing Address - Phone:803-438-8234
Mailing Address - Fax:803-438-8234
Practice Address - Street 1:1053 HWY 1
Practice Address - Street 2:PATTERSON PLAZA
Practice Address - City:LUGOFF
Practice Address - State:SC
Practice Address - Zip Code:29078
Practice Address - Country:US
Practice Address - Phone:803-438-8234
Practice Address - Fax:803-438-8234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDE2385Medicaid
SCDE2385Medicaid