Provider Demographics
NPI:1558572362
Name:ELGIN PHARAMACY
Entity Type:Organization
Organization Name:ELGIN PHARAMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:FREDDY
Authorized Official - Middle Name:
Authorized Official - Last Name:MUBARAK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:803-438-5735
Mailing Address - Street 1:PO BOX 749
Mailing Address - Street 2:1107 ROSS ST.
Mailing Address - City:ELGIN
Mailing Address - State:SC
Mailing Address - Zip Code:29045-0749
Mailing Address - Country:US
Mailing Address - Phone:803-438-5732
Mailing Address - Fax:803-438-4657
Practice Address - Street 1:1107 ROSS ST.
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:SC
Practice Address - Zip Code:29045
Practice Address - Country:US
Practice Address - Phone:803-438-5732
Practice Address - Fax:803-438-4657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC50002037332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC720376Medicaid
SC1145010001Medicare ID - Type Unspecified