Provider Demographics
NPI:1295095487
Name:CIVIC MEDICATION MANAGEMENT SERVICES LLC
Entity type:Organization
Organization Name:CIVIC MEDICATION MANAGEMENT SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:MONIQUE
Authorized Official - Last Name:BURKS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:843-830-8702
Mailing Address - Street 1:PO BOX 61934
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29419-1934
Mailing Address - Country:US
Mailing Address - Phone:843-830-8702
Mailing Address - Fax:843-824-2216
Practice Address - Street 1:8471 YADKIN CIR APT H
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9544
Practice Address - Country:US
Practice Address - Phone:843-830-8702
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-21
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLIC-1-13-89601183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty