Provider Demographics
NPI:1821599937
Name:FETTER FAMILY HEALTH CENTER INC
Entity Type:Organization
Organization Name:FETTER FAMILY HEALTH CENTER INC
Other - Org Name:ELIJAH WRIGHT HEALTH CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ARETHA
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-722-4112
Mailing Address - Street 1:1681 OLD HIGHWAY 6
Mailing Address - Street 2:
Mailing Address - City:CROSS
Mailing Address - State:SC
Mailing Address - Zip Code:29436-3602
Mailing Address - Country:US
Mailing Address - Phone:843-753-2334
Mailing Address - Fax:843-853-2966
Practice Address - Street 1:1681 OLD HIGHWAY 6
Practice Address - Street 2:
Practice Address - City:CROSS
Practice Address - State:SC
Practice Address - Zip Code:29436-3602
Practice Address - Country:US
Practice Address - Phone:843-720-5655
Practice Address - Fax:843-853-2966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-23
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
SC178113336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2175773OtherPK
SC717811Medicaid