Provider Demographics
NPI:1952632234
Name:MEDICAL UNIVERSITY HOSPITAL AUTHORITY
Entity Type:Organization
Organization Name:MEDICAL UNIVERSITY HOSPITAL AUTHORITY
Other - Org Name:MUSC HEALTH - HF MABRY CANCER CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORPORATE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ERICKA
Authorized Official - Middle Name:A
Authorized Official - Last Name:SOMMERS WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-792-7810
Mailing Address - Street 1:1161 COOK RD
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29118-8204
Mailing Address - Country:US
Mailing Address - Phone:803-395-2730
Mailing Address - Fax:803-395-2731
Practice Address - Street 1:1161 COOK RD
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-8204
Practice Address - Country:US
Practice Address - Phone:803-395-2730
Practice Address - Fax:803-395-2731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-26
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0002X
SC49193336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC7Z1258Medicaid
SC21182OtherSTATE PHARMACY LICENSE