Provider Demographics
NPI:1790772598
Name:M J W CORPORTATION
Entity Type:Organization
Organization Name:M J W CORPORTATION
Other - Org Name:FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:BRANDI
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:803-648-1776
Mailing Address - Street 1:333 NEWBERRY ST NW
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29801-3929
Mailing Address - Country:US
Mailing Address - Phone:803-649-1776
Mailing Address - Fax:803-641-0205
Practice Address - Street 1:333 NEWBERRY ST NW
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-3929
Practice Address - Country:US
Practice Address - Phone:803-649-1776
Practice Address - Fax:803-641-0205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-05
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
SC26933336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC726932Medicaid
SCDME636Medicaid
2089675OtherPK
SCDME636Medicaid