Provider Demographics
NPI:1942270582
Name:SPARTANBURG REGIONAL HEALTH SERVICES DISTRICT INC
Entity Type:Organization
Organization Name:SPARTANBURG REGIONAL HEALTH SERVICES DISTRICT INC
Other - Org Name:SRHS PHARMACY GIBBS - CAROLINA UPSTATE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPERATIONS MANAGER - RETAIL PHARMAC
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:GENTILCORE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:864-560-1864
Mailing Address - Street 1:380 SERPENTINE DR
Mailing Address - Street 2:STE 201
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29303-3066
Mailing Address - Country:US
Mailing Address - Phone:864-560-1864
Mailing Address - Fax:864-560-0864
Practice Address - Street 1:380 SERPENTINE DR
Practice Address - Street 2:STE 201
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3066
Practice Address - Country:US
Practice Address - Phone:864-560-1864
Practice Address - Fax:864-560-0864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-25
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X
SC102373336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC710237Medicaid
2125027OtherPK
SC10237OtherSC BOARD OF PHARMACY