Provider Demographics
NPI:1821139460
Name:PEACH VALLEY PHARMACY, INC.
Entity Type:Organization
Organization Name:PEACH VALLEY PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:H
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-577-0087
Mailing Address - Street 1:2306 CHESNEE HWY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29303-5500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2306 CHESNEE HWY
Practice Address - Street 2:SUITE 1
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-5500
Practice Address - Country:US
Practice Address - Phone:864-577-0087
Practice Address - Fax:864-577-0599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCDE1599332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC750351Medicaid
SCDE1599Medicaid
SCDE1599Medicaid