Provider Demographics
NPI:1679670517
Name:MEDICINE MART OF GAFFNEY
Entity Type:Organization
Organization Name:MEDICINE MART OF GAFFNEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:ROY
Authorized Official - Middle Name:
Authorized Official - Last Name:FLYNN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-968-7000
Mailing Address - Street 1:305 N LIMESTONE ST
Mailing Address - Street 2:
Mailing Address - City:GAFFNEY
Mailing Address - State:SC
Mailing Address - Zip Code:29340-3171
Mailing Address - Country:US
Mailing Address - Phone:864-489-5198
Mailing Address - Fax:864-488-9297
Practice Address - Street 1:305 N LIMESTONE ST
Practice Address - Street 2:
Practice Address - City:GAFFNEY
Practice Address - State:SC
Practice Address - Zip Code:29340-3171
Practice Address - Country:US
Practice Address - Phone:864-489-5198
Practice Address - Fax:864-488-9297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2019-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
SC173523336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC717352Medicaid
2170367OtherPK