Provider Demographics
NPI:1962861922
Name:BEAUFORT PHARMACY LLC
Entity Type:Organization
Organization Name:BEAUFORT PHARMACY LLC
Other - Org Name:BEAUFORT PHARMACY AND COMPOUDING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:843-379-3278
Mailing Address - Street 1:968 RIBAUT RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902-8000
Mailing Address - Country:US
Mailing Address - Phone:843-379-3278
Mailing Address - Fax:843-379-3232
Practice Address - Street 1:968 RIBAUT RD STE 1
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-8003
Practice Address - Country:US
Practice Address - Phone:843-379-3278
Practice Address - Fax:843-379-3232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-18
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 333600000X
SC164733336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC716473Medicaid
2159036OtherPK