Provider Demographics
NPI:1972690857
Name:PIGGLY WIGGLY SOUTH INC
Entity Type:Organization
Organization Name:PIGGLY WIGGLY SOUTH INC
Other - Org Name:SUP RX PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MCLEOD
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:803-773-6378
Mailing Address - Street 1:1455 S GUIGNARD DR
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-7479
Mailing Address - Country:US
Mailing Address - Phone:803-778-5758
Mailing Address - Fax:803-778-5763
Practice Address - Street 1:1455 S GUIGNARD DR
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-7479
Practice Address - Country:US
Practice Address - Phone:803-778-5758
Practice Address - Fax:803-778-5763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
SC50383336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC729866Medicaid
2091737OtherPK
SC750384Medicaid