Provider Demographics
NPI:1942205950
Name:PALMETTO PHARMACY ENTERPRISES LLC
Entity Type:Organization
Organization Name:PALMETTO PHARMACY ENTERPRISES LLC
Other - Org Name:PALMETTO PHARMACY ENTERPRISES LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-943-9327
Mailing Address - Street 1:PO BOX 853
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:SC
Mailing Address - Zip Code:29924-0853
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:810 ELM ST E
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:SC
Practice Address - Zip Code:29924-2610
Practice Address - Country:US
Practice Address - Phone:803-943-9327
Practice Address - Fax:803-943-9329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-16
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
SC500075433336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC775431Medicaid
4225240OtherNCPDP PROVIDER IDENTIFICATION NUMBER
SCDE2489Medicaid