Provider Demographics
NPI:1508109497
Name:BRUNSON'S PHARMACY, LLC
Entity Type:Organization
Organization Name:BRUNSON'S PHARMACY, LLC
Other - Org Name:BRUNSON'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:V
Authorized Official - Last Name:MATHIS
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:803-435-2511
Mailing Address - Street 1:PO BOX 1250
Mailing Address - Street 2:12 N BROOKS ST
Mailing Address - City:MANNING
Mailing Address - State:SC
Mailing Address - Zip Code:29102-1250
Mailing Address - Country:US
Mailing Address - Phone:803-435-2511
Mailing Address - Fax:
Practice Address - Street 1:12 N BROOKS ST
Practice Address - Street 2:SUITE 206
Practice Address - City:MANNING
Practice Address - State:SC
Practice Address - Zip Code:29102-3206
Practice Address - Country:US
Practice Address - Phone:803-435-2511
Practice Address - Fax:803-435-4235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-29
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC14411333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4231217OtherNCPDP PROVIDER IDENTIFICATION NUMBER
SC714411Medicaid