Provider Demographics
NPI:1508008202
Name:DELTA OF CHARLESTON, INC
Entity type:Organization
Organization Name:DELTA OF CHARLESTON, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VAN
Authorized Official - Middle Name:WILLIS
Authorized Official - Last Name:HIGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-761-5255
Mailing Address - Street 1:402 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MONCKS CORNER
Mailing Address - State:SC
Mailing Address - Zip Code:29461-3616
Mailing Address - Country:US
Mailing Address - Phone:843-761-5255
Mailing Address - Fax:843-761-5255
Practice Address - Street 1:346 E BAY ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29401-1551
Practice Address - Country:US
Practice Address - Phone:843-937-0960
Practice Address - Fax:843-937-0960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-27
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy