Provider Demographics
NPI:1740788066
Name:ZIVITSKI HEALTH GROUP LLC
Entity Type:Organization
Organization Name:ZIVITSKI HEALTH GROUP LLC
Other - Org Name:GRAY COURT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:ZIVITSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-876-3837
Mailing Address - Street 1:PO BOX 96
Mailing Address - Street 2:
Mailing Address - City:GRAY COURT
Mailing Address - State:SC
Mailing Address - Zip Code:29645-0096
Mailing Address - Country:US
Mailing Address - Phone:864-876-3837
Mailing Address - Fax:864-876-1137
Practice Address - Street 1:345 W MAIN STREET
Practice Address - Street 2:
Practice Address - City:GRAY COURT
Practice Address - State:SC
Practice Address - Zip Code:29645
Practice Address - Country:US
Practice Address - Phone:864-876-3837
Practice Address - Fax:864-876-1137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-01
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
SC176633336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2177354OtherPK
SC711725Medicaid