Provider Demographics
NPI:1336424167
Name:LAKE WYLIE HEALTH INVESTORS INC
Entity Type:Organization
Organization Name:LAKE WYLIE HEALTH INVESTORS INC
Other - Org Name:LAKE WYLIE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCHUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-240-9882
Mailing Address - Street 1:PO BOX 5343
Mailing Address - Street 2:
Mailing Address - City:LAKE WYLIE
Mailing Address - State:SC
Mailing Address - Zip Code:29710-5004
Mailing Address - Country:US
Mailing Address - Phone:803-831-2044
Mailing Address - Fax:803-939-8389
Practice Address - Street 1:221 LATITUDE LN STE 109
Practice Address - Street 2:
Practice Address - City:LAKE WYLIE
Practice Address - State:SC
Practice Address - Zip Code:29710-8117
Practice Address - Country:US
Practice Address - Phone:803-831-2044
Practice Address - Fax:803-939-8489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-12
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
SC136653336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
4230479OtherNCPDP PROVIDER IDENTIFICATION NUMBER
4230479OtherNCPDP PROVIDER IDENTIFICATION NUMBER