Provider Demographics
NPI:1306829668
Name:PROFESSIONAL PHARMACY AT MT VIEW IN
Entity Type:Organization
Organization Name:PROFESSIONAL PHARMACY AT MT VIEW IN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:JAGINA
Authorized Official - Last Name:KING
Authorized Official - Suffix:JR
Authorized Official - Credentials:RPH
Authorized Official - Phone:864-877-4281
Mailing Address - Street 1:428 MEMORIAL DRIVE EXT
Mailing Address - Street 2:
Mailing Address - City:GREER
Mailing Address - State:SC
Mailing Address - Zip Code:29651-1818
Mailing Address - Country:US
Mailing Address - Phone:864-877-4281
Mailing Address - Fax:864-877-4077
Practice Address - Street 1:428 MEMORIAL DRIVE EXTENSION
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29651-1818
Practice Address - Country:US
Practice Address - Phone:864-877-4281
Practice Address - Fax:864-877-4077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-21
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
SC500015043336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC715040Medicaid
4210592OtherNABP NUMBER
0252970001Medicare ID - Type Unspecified