Provider Demographics
NPI:1356402309
Name:PALMETTO HEALTH
Entity type:Organization
Organization Name:PALMETTO HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CORPORATE DIRECTOR PFS
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:ECKERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-296-2548
Mailing Address - Street 1:3301 HARDEN ST
Mailing Address - Street 2:EXT 10 MEDICAL PARK DRIVE
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-6897
Mailing Address - Country:US
Mailing Address - Phone:803-296-2548
Mailing Address - Fax:803-296-2548
Practice Address - Street 1:3301 HARDEN ST
Practice Address - Street 2:EXT 10 MEDICAL PARK DRIVE
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6897
Practice Address - Country:US
Practice Address - Phone:803-296-2548
Practice Address - Fax:803-296-2548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC040573030333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC742544Medicaid
SC4207468Medicaid