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
State | License ID | Taxonomies |
---|---|---|
SC | 14285 | 3336C0004X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 3336C0004X | Suppliers | Pharmacy | Compounding Pharmacy |