Provider Demographics
NPI:1740219732
Name:NINETY SIX PHARMACY, INC.
Entity Type:Organization
Organization Name:NINETY SIX PHARMACY, INC.
Other - Org Name:FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:HAMPTON
Authorized Official - Last Name:LONG
Authorized Official - Suffix:II
Authorized Official - Credentials:RPH
Authorized Official - Phone:864-543-2852
Mailing Address - Street 1:206 N CAMBRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:NINETY SIX
Mailing Address - State:SC
Mailing Address - Zip Code:29666-1011
Mailing Address - Country:US
Mailing Address - Phone:864-543-2852
Mailing Address - Fax:864-543-2982
Practice Address - Street 1:206 N CAMBRIDGE ST
Practice Address - Street 2:
Practice Address - City:NINETY SIX
Practice Address - State:SC
Practice Address - Zip Code:29666-1011
Practice Address - Country:US
Practice Address - Phone:864-543-2852
Practice Address - Fax:864-543-2982
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3458183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC50004038OtherSTATE LICENSE NUMBER
SCDME330Medicaid
SC50004038OtherSTATE LICENSE NUMBER