Provider Demographics
NPI:1508816802
Name:GREENVILLE HEALTH CORPORATION
Entity Type:Organization
Organization Name:GREENVILLE HEALTH CORPORATION
Other - Org Name:UPSTATE MEDICAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP PAYOR STRATEGIES & ALIGNMENT
Authorized Official - Prefix:
Authorized Official - First Name:POLLY
Authorized Official - Middle Name:H
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-522-2286
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-455-7000
Mailing Address - Fax:
Practice Address - Street 1:701 GROVE RD
Practice Address - Street 2:EMPLOYEE PAVILION
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-5611
Practice Address - Country:US
Practice Address - Phone:864-455-8910
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10-02663333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDE1459Medicaid
SC4217801OtherNABP #
SC726635Medicaid
SC726635Medicaid
SC10-02663OtherSTATE DEA
SCBU2933821OtherFEDERAL DEA
SCQ275850002Medicare ID - Type UnspecifiedMEDICARE