Provider Demographics
NPI:1417341132
Name:TIDEWATER PHARMACY & MEDICAL SUPPLY LLC
Entity Type:Organization
Organization Name:TIDEWATER PHARMACY & MEDICAL SUPPLY LLC
Other - Org Name:TIDEWATER PHARMACY & COMPOUNDING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:STRAUGHAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:478-954-1178
Mailing Address - Street 1:421 JOHNNIE DODDS BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-2689
Mailing Address - Country:US
Mailing Address - Phone:478-954-1178
Mailing Address - Fax:843-375-6311
Practice Address - Street 1:421 JOHNNIE DODDS BLVD
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464
Practice Address - Country:US
Practice Address - Phone:843-375-6310
Practice Address - Fax:843-375-6311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-19
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC35780332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies