Provider Demographics
NPI:1275929218
Name:DELTA OF ISLE OF PALMS LLC
Entity Type:Organization
Organization Name:DELTA OF ISLE OF PALMS LLC
Other - Org Name:DELTA PHARMACY & MEDICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANDRIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WELCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-761-5255
Mailing Address - Street 1:402 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MONCKS CORNER
Mailing Address - State:SC
Mailing Address - Zip Code:29461-3616
Mailing Address - Country:US
Mailing Address - Phone:843-761-5255
Mailing Address - Fax:843-899-4970
Practice Address - Street 1:1400 PALM BLVD
Practice Address - Street 2:
Practice Address - City:ISLE OF PALMS
Practice Address - State:SC
Practice Address - Zip Code:29451-2280
Practice Address - Country:US
Practice Address - Phone:843-885-8008
Practice Address - Fax:843-899-4970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-07
Last Update Date:2015-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC158543336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2150847OtherPK