Provider Demographics
NPI:1649250333
Name:HEDGEMARK BRENTWOOD PHARMACY, INC.
Entity type:Organization
Organization Name:HEDGEMARK BRENTWOOD PHARMACY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:V-PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:S
Authorized Official - Last Name:DURRENCE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:843-762-1177
Mailing Address - Street 1:1548 ASHLEY RIVER ROAD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407
Mailing Address - Country:US
Mailing Address - Phone:843-762-1177
Mailing Address - Fax:843-762-4506
Practice Address - Street 1:1548 ASHLEY RIVER ROAD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407
Practice Address - Country:US
Practice Address - Phone:843-762-1177
Practice Address - Fax:843-762-4506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-19
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332BC3200X, 332BP3500X, 332BX2000X, 332B00000X
SC50-002227333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC561663Medicaid
SC=========003OtherBC/BS IDENTIFICATION NUM
SC0537110001Medicare NSC