Provider Demographics
NPI: | 1497184667 |
---|---|
Name: | CHARLESTON ENT ASSOCIATES LLC |
Entity Type: | Organization |
Organization Name: | CHARLESTON ENT ASSOCIATES LLC |
Other - Org Name: | CHARLESTON ENT SMP |
Other - Org Type: | Other Name |
Authorized Official - Title/Position: | DIRECTOR OF PHARMACY |
Authorized Official - Prefix: | |
Authorized Official - First Name: | JAMES |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | VECCHIOLLA |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 843-793-6402 |
Mailing Address - Street 1: | 2295 HENRY TECKLENBURG DR |
Mailing Address - Street 2: | |
Mailing Address - City: | CHARLESTON |
Mailing Address - State: | SC |
Mailing Address - Zip Code: | 29414-7801 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 843-793-6402 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 180 WINGO WAY |
Practice Address - Street 2: | SUITE 103 |
Practice Address - City: | MT PLEASANT |
Practice Address - State: | SC |
Practice Address - Zip Code: | 29464-1810 |
Practice Address - Country: | US |
Practice Address - Phone: | 843-216-8774 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2013-11-07 |
Last Update Date: | 2014-06-10 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
SC | 22628 | 3336C0002X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 3336C0002X | Suppliers | Pharmacy | Clinic Pharmacy |