Provider Demographics
NPI:1760589600
Name:PIGGLY WIGGLY #35
Entity Type:Organization
Organization Name:PIGGLY WIGGLY #35
Other - Org Name:SUP RX PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:W R
Authorized Official - Middle Name:
Authorized Official - Last Name:MCLEOD
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:803-775-1334
Mailing Address - Street 1:842 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:HARTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29550-5697
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:842 S 5TH ST
Practice Address - Street 2:
Practice Address - City:HARTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29550-5697
Practice Address - Country:US
Practice Address - Phone:843-332-0762
Practice Address - Fax:843-383-9576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC50008929333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4213106OtherOTHER ID NUMBER-COMMERCIAL NUMBER
SC718178Medicaid