Provider Demographics
NPI:1619485992
Name:REDEC PHARMACY
Entity Type:Organization
Organization Name:REDEC PHARMACY
Other - Org Name:REDEC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:HEWIS
Authorized Official - Middle Name:
Authorized Official - Last Name:BARTELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-919-8881
Mailing Address - Street 1:200 N DOBYS BRIDGE RD STE 124
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29715-2084
Mailing Address - Country:US
Mailing Address - Phone:803-802-3001
Mailing Address - Fax:803-802-3915
Practice Address - Street 1:200 N DOBYS BRIDGE RD STE 124
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715-2084
Practice Address - Country:US
Practice Address - Phone:803-802-3915
Practice Address - Fax:803-802-3915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-20
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
SC177323336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC717732Medicaid
2175595OtherPK