Provider Demographics
NPI:1689768376
Name:THE FORMS BOUTIQUE, INC.
Entity Type:Organization
Organization Name:THE FORMS BOUTIQUE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:D
Authorized Official - Last Name:MCLELLAN
Authorized Official - Suffix:
Authorized Official - Credentials:RFM, CMF
Authorized Official - Phone:803-799-7096
Mailing Address - Street 1:3308 FOREST DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-4024
Mailing Address - Country:US
Mailing Address - Phone:803-738-8400
Mailing Address - Fax:803-738-8498
Practice Address - Street 1:3308 FOREST DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-4024
Practice Address - Country:US
Practice Address - Phone:803-738-8400
Practice Address - Fax:803-738-8498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC556570Medicaid
SC0183650001Medicare ID - Type Unspecified