Provider Demographics
NPI:1659360873
Name:MCLEOD HEALTH CLARENDON LTC PHARMACY
Entity Type:Organization
Organization Name:MCLEOD HEALTH CLARENDON LTC PHARMACY
Other - Org Name:CYPRESS CENTER LTC PHARMACY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:SR VP AND CFO
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:FULTON
Authorized Official - Last Name:ERVIN
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:843-777-2910
Mailing Address - Street 1:50 E HOSPITAL ST
Mailing Address - Street 2:STE 1B
Mailing Address - City:MANNING
Mailing Address - State:SC
Mailing Address - Zip Code:29102-3149
Mailing Address - Country:US
Mailing Address - Phone:803-435-5272
Mailing Address - Fax:803-435-5271
Practice Address - Street 1:50 E HOSPITAL ST
Practice Address - Street 2:STE 1B
Practice Address - City:MANNING
Practice Address - State:SC
Practice Address - Zip Code:29102-3149
Practice Address - Country:US
Practice Address - Phone:803-435-5272
Practice Address - Fax:803-435-5271
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MCLEOD HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-20
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC16726333600000X
3336L0003X, 183500000X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336L0003XSuppliersPharmacyLong Term Care PharmacyGroup - Single Specialty
Yes333600000XSuppliersPharmacyGroup - Multi-Specialty
No183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC722205Medicaid
2163851OtherPK