Provider Demographics
NPI:1790848976
Name:FAIRFAX PHARMACY INC.
Entity Type:Organization
Organization Name:FAIRFAX PHARMACY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:B
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-632-2055
Mailing Address - Street 1:PO BOX 366
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:SC
Mailing Address - Zip Code:29827-0366
Mailing Address - Country:US
Mailing Address - Phone:803-632-2055
Mailing Address - Fax:803-632-1708
Practice Address - Street 1:1275 ALLENDALE FAIRFAX HWY
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:SC
Practice Address - Zip Code:29827-9124
Practice Address - Country:US
Practice Address - Phone:803-632-2055
Practice Address - Fax:803-632-1708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC50005433332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDE1145Medicaid