Provider Demographics
NPI:1558756072
Name:GUSTAFSONS APOTHECARY LLC
Entity Type:Organization
Organization Name:GUSTAFSONS APOTHECARY LLC
Other - Org Name:LANDY'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:YALANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:GAMBLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-738-5706
Mailing Address - Street 1:835 SPARKLEBERRY LANE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229
Mailing Address - Country:US
Mailing Address - Phone:803-567-3107
Mailing Address - Fax:
Practice Address - Street 1:835 SPARKLEBERRY LANE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29229-2922
Practice Address - Country:US
Practice Address - Phone:803-567-3107
Practice Address - Fax:803-736-6228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-01
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC158373336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2150419OtherPK
SC715837Medicaid