Provider Demographics
NPI:1568527752
Name:WALTER W ROGAN
Entity Type:Organization
Organization Name:WALTER W ROGAN
Other - Org Name:GREELEYVILLE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:W
Authorized Official - Last Name:ROGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-426-2170
Mailing Address - Street 1:PO BOX 277
Mailing Address - Street 2:
Mailing Address - City:GREELEYVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29056-0277
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:215 VARNER AVE
Practice Address - Street 2:
Practice Address - City:GREELEYVILLE
Practice Address - State:SC
Practice Address - Zip Code:29056-0000
Practice Address - Country:US
Practice Address - Phone:843-426-2170
Practice Address - Fax:843-426-2166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
SC17023336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2089102OtherPK
SC717056Medicaid