Provider Demographics
NPI:1528395944
Name:DELTA OF DANIEL ISLAND LLC
Entity Type:Organization
Organization Name:DELTA OF DANIEL ISLAND LLC
Other - Org Name:DELTA OF DANIEL ISLAND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANGER
Authorized Official - Prefix:
Authorized Official - First Name:ANDRIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WELCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-761-5255
Mailing Address - Street 1:402 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MONCKS CORNER
Mailing Address - State:SC
Mailing Address - Zip Code:29461-3616
Mailing Address - Country:US
Mailing Address - Phone:843-761-5255
Mailing Address - Fax:843-899-4970
Practice Address - Street 1:162 SEVEN FARMS DR STE 125
Practice Address - Street 2:
Practice Address - City:DANIEL ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29492-8034
Practice Address - Country:US
Practice Address - Phone:843-471-2870
Practice Address - Fax:843-899-4970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-05
Last Update Date:2015-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
SC106803336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2122631OtherPK