Provider Demographics
NPI:1932306727
Name:BLYTHEWOOD PROFESSIONAL DRUG COMPANY
Entity Type:Organization
Organization Name:BLYTHEWOOD PROFESSIONAL DRUG COMPANY
Other - Org Name:BLYTHEWOOD PHARMACY AND HOME MEDICAL EQUIPMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:E.
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:THAMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-786-8110
Mailing Address - Street 1:PO BOX 803
Mailing Address - Street 2:
Mailing Address - City:BLYTHEWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29016-0803
Mailing Address - Country:US
Mailing Address - Phone:803-786-8110
Mailing Address - Fax:803-735-3302
Practice Address - Street 1:710 UNIVERSITY VILLAGE DR STE C
Practice Address - Street 2:
Practice Address - City:BLYTHEWOOD
Practice Address - State:SC
Practice Address - Zip Code:29016-7611
Practice Address - Country:US
Practice Address - Phone:803-786-8110
Practice Address - Fax:803-735-3302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC50008013332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDE2527Medicaid
SCDE2527Medicaid