Provider Demographics
NPI:1205352374
Name:CAROLINA HEALTH PHARMACY LLC
Entity type:Organization
Organization Name:CAROLINA HEALTH PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMEH
Authorized Official - Middle Name:
Authorized Official - Last Name:IBRAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-215-8200
Mailing Address - Street 1:4036 RIVER OAKS DR UNIT B-1
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-6695
Mailing Address - Country:US
Mailing Address - Phone:843-236-6500
Mailing Address - Fax:843-584-8534
Practice Address - Street 1:4036 RIVER OAKS DR UNIT B-1
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-6695
Practice Address - Country:US
Practice Address - Phone:843-236-6500
Practice Address - Fax:843-584-8534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-20
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC717565Medicaid