Provider Demographics
NPI:1366509440
Name:PIGGLY WIGGLY LAKE CITY, INC.
Entity Type:Organization
Organization Name:PIGGLY WIGGLY LAKE CITY, INC.
Other - Org Name:PIGGLY WIGGLY PHARMACY #48
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:R
Authorized Official - Last Name:SCHOOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-554-9880
Mailing Address - Street 1:PO BOX 118047
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29423-8047
Mailing Address - Country:US
Mailing Address - Phone:843-554-9980
Mailing Address - Fax:843-202-8211
Practice Address - Street 1:269 N RON MCNAIR BLVD
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:SC
Practice Address - Zip Code:29560-2437
Practice Address - Country:US
Practice Address - Phone:843-394-3121
Practice Address - Fax:843-394-2551
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PIGGLY WIGGLY CAROLINA CO. INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-02
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5001776332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC717766Medicaid
SC0461080001Medicare NSC