Provider Demographics
NPI:1568081024
Name:LOWCOUNTRY STREET GROCERY
Entity Type:Organization
Organization Name:LOWCOUNTRY STREET GROCERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:OLIVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-661-9975
Mailing Address - Street 1:1108 WAPPOO RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-5954
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1108 WAPPOO RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-5954
Practice Address - Country:US
Practice Address - Phone:843-609-8188
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-14
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty