Provider Demographics
NPI:1598858987
Name:THE MEDICINE MART OF WEST COLUMBIA, INC
Entity Type:Organization
Organization Name:THE MEDICINE MART OF WEST COLUMBIA, INC
Other - Org Name:MEDICINE MART
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:ELTON
Authorized Official - Last Name:CONNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:803-791-7043
Mailing Address - Street 1:1300 SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-5914
Mailing Address - Country:US
Mailing Address - Phone:803-791-7043
Mailing Address - Fax:803-796-1519
Practice Address - Street 1:1300 SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-5914
Practice Address - Country:US
Practice Address - Phone:803-791-7043
Practice Address - Fax:803-796-1519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-30
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC50006495183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC717584Medicaid
SC0124770001Medicare NSC