Provider Demographics
NPI:1548769219
Name:LONG'S DRUGSTORES OF SOUTH CAROLINA, INC.
Entity Type:Organization
Organization Name:LONG'S DRUGSTORES OF SOUTH CAROLINA, INC.
Other - Org Name:AVITA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORPORATE COUNSEL
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-254-5884
Mailing Address - Street 1:811 PENDLETON ST STE 10
Mailing Address - Street 2:SUITE 10
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-3232
Mailing Address - Country:US
Mailing Address - Phone:803-254-5884
Mailing Address - Fax:866-550-7461
Practice Address - Street 1:811 PENDLETON ST STE 10
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601-3232
Practice Address - Country:US
Practice Address - Phone:803-254-5884
Practice Address - Fax:866-550-7461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-07
Last Update Date:2018-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
SC176233336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2175693OtherPK