Provider Demographics
NPI:1922029644
Name:PEAK PHARMACY INC
Entity Type:Organization
Organization Name:PEAK PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PIC
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY JO
Authorized Official - Middle Name:SMITH
Authorized Official - Last Name:DYCHES
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:803-345-1707
Mailing Address - Street 1:PO BOX 39
Mailing Address - Street 2:22 RIVER STREET
Mailing Address - City:PEAK
Mailing Address - State:SC
Mailing Address - Zip Code:29122
Mailing Address - Country:US
Mailing Address - Phone:803-345-1707
Mailing Address - Fax:803-345-8952
Practice Address - Street 1:22 RIVER STREET
Practice Address - Street 2:
Practice Address - City:PEAK
Practice Address - State:SC
Practice Address - Zip Code:29122
Practice Address - Country:US
Practice Address - Phone:803-345-1707
Practice Address - Fax:803-345-8952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC50000529333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4206050OtherNABP
SC705291Medicaid
SC705291Medicaid