Provider Demographics
NPI:1659385078
Name:VASSAR C.LIVENGOOD
Entity Type:Organization
Organization Name:VASSAR C.LIVENGOOD
Other - Org Name:SLATER DRUG COMPANY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VASSAR
Authorized Official - Middle Name:CHUMLEY
Authorized Official - Last Name:LIVENGOOD
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:864-836-3771
Mailing Address - Street 1:PO BOX 156
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:SC
Mailing Address - Zip Code:29661-0156
Mailing Address - Country:US
Mailing Address - Phone:864-836-3771
Mailing Address - Fax:864-836-6330
Practice Address - Street 1:101 PUMPKINTOWN RD
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:SC
Practice Address - Zip Code:29661
Practice Address - Country:US
Practice Address - Phone:864-836-3771
Practice Address - Fax:864-836-6330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3977183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDM0628Medicaid
SCDM0628Medicaid