Provider Demographics
NPI:1467002816
Name:BLACK RIVER PHARMACY LLC
Entity Type:Organization
Organization Name:BLACK RIVER PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:DRUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:843-356-0172
Mailing Address - Street 1:32A N WILLIAMSBURG COUNTY HWY
Mailing Address - Street 2:
Mailing Address - City:KINGSTREE
Mailing Address - State:SC
Mailing Address - Zip Code:29556-2433
Mailing Address - Country:US
Mailing Address - Phone:843-355-5656
Mailing Address - Fax:843-355-5655
Practice Address - Street 1:32A N WILLIAMSBURG COUNTY HWY
Practice Address - Street 2:
Practice Address - City:KINGSTREE
Practice Address - State:SC
Practice Address - Zip Code:29556-2433
Practice Address - Country:US
Practice Address - Phone:843-355-5656
Practice Address - Fax:843-355-5655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-18
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy