Provider Demographics
NPI:1689868325
Name:MEDICINE MAN PHARMACY L.L.C.
Entity Type:Organization
Organization Name:MEDICINE MAN PHARMACY L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:MISSROON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:843-871-6944
Mailing Address - Street 1:404 TROLLEY RD
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29485-5661
Mailing Address - Country:US
Mailing Address - Phone:843-871-6974
Mailing Address - Fax:843-851-9548
Practice Address - Street 1:404 TROLLEY RD
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485-5661
Practice Address - Country:US
Practice Address - Phone:843-871-6974
Practice Address - Fax:843-851-9548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-05
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1568333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy