Provider Demographics
NPI:1598758955
Name:PROFESSIONAL PHARMACY SERVICES, INC
Entity Type:Organization
Organization Name:PROFESSIONAL PHARMACY SERVICES, INC
Other - Org Name:COASTAL RESPIRATORY AND BRACE STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:KYLE
Authorized Official - Last Name:STURGEON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-665-4051
Mailing Address - Street 1:PO BOX 7487
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29502-7487
Mailing Address - Country:US
Mailing Address - Phone:843-665-4051
Mailing Address - Fax:843-799-2493
Practice Address - Street 1:773 MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTH MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29582-3029
Practice Address - Country:US
Practice Address - Phone:843-665-4051
Practice Address - Fax:843-799-2493
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-31
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC50-006977332BP3500X
332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC769771Medicaid
SCDME-197Medicaid
SCC08454597Medicare ID - Type UnspecifiedMEDICARE SUBMITTER NUMBER
SC769771Medicaid