Provider Demographics
NPI:1184961641
Name:SUP - RX PHARMACY #92
Entity type:Organization
Organization Name:SUP - RX PHARMACY #92
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:BRYAN
Authorized Official - Last Name:MOODY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:843-673-9107
Mailing Address - Street 1:PO BOX 3238
Mailing Address - Street 2:1945 WEST PALMETTO ST SUITE 32
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-3919
Mailing Address - Country:US
Mailing Address - Phone:843-673-9107
Mailing Address - Fax:843-673-9109
Practice Address - Street 1:1945 W PALMETTO ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-3919
Practice Address - Country:US
Practice Address - Phone:843-673-9107
Practice Address - Fax:843-673-9109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-03
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy