Provider Demographics
NPI:1710228440
Name:BRUNSON'S PHARMACY, LLC
Entity Type:Organization
Organization Name:BRUNSON'S PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PIC
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:VICTOR
Authorized Official - Last Name:MATHIS
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHARMD, RPH
Authorized Official - Phone:803-435-2511
Mailing Address - Street 1:PO BOX 1250
Mailing Address - Street 2:
Mailing Address - City:MANNING
Mailing Address - State:SC
Mailing Address - Zip Code:29102-1250
Mailing Address - Country:US
Mailing Address - Phone:803-435-2511
Mailing Address - Fax:
Practice Address - Street 1:12 N BROOKS ST
Practice Address - Street 2:
Practice Address - City:MANNING
Practice Address - State:SC
Practice Address - Zip Code:29102-3206
Practice Address - Country:US
Practice Address - Phone:803-435-2511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-05
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11113183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty