Provider Demographics
NPI:1750489688
Name:MAULDIN FAMILY PHARMACY INC
Entity Type:Organization
Organization Name:MAULDIN FAMILY PHARMACY INC
Other - Org Name:MAULDIN FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:TIDMARSH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:864-288-2600
Mailing Address - Street 1:505 N MAIN ST
Mailing Address - Street 2:STE A
Mailing Address - City:MAULDIN
Mailing Address - State:SC
Mailing Address - Zip Code:29662-2345
Mailing Address - Country:US
Mailing Address - Phone:864-288-2600
Mailing Address - Fax:864-288-5608
Practice Address - Street 1:505 N MAIN ST
Practice Address - Street 2:STE A
Practice Address - City:MAULDIN
Practice Address - State:SC
Practice Address - Zip Code:29662-2345
Practice Address - Country:US
Practice Address - Phone:864-288-2600
Practice Address - Fax:864-288-5608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
SC18743336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2089291OtherPK
SC718748Medicaid
0254760001Medicare NSC