Provider Demographics
NPI:1437495223
Name:PAWLEYS ISLAND COMPOUNDING PHARMACY LLC
Entity type:Organization
Organization Name:PAWLEYS ISLAND COMPOUNDING PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:LEWIS
Authorized Official - Middle Name:
Authorized Official - Last Name:WALDREP
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:843-235-0580
Mailing Address - Street 1:9710 OCEAN HWY UNIT 2
Mailing Address - Street 2:
Mailing Address - City:PAWLEYS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29585-7585
Mailing Address - Country:US
Mailing Address - Phone:843-235-0580
Mailing Address - Fax:
Practice Address - Street 1:9710 OCEAN HWY UNIT 2
Practice Address - Street 2:
Practice Address - City:PAWLEYS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29585-7585
Practice Address - Country:US
Practice Address - Phone:843-235-0580
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-24
Last Update Date:2012-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC142853336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy