Provider Demographics
NPI:1700881943
Name:LORIS DRUG STORE, INC.
Entity Type:Organization
Organization Name:LORIS DRUG STORE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:SINGLETON
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-756-4021
Mailing Address - Street 1:4125 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LORIS
Mailing Address - State:SC
Mailing Address - Zip Code:29569-3023
Mailing Address - Country:US
Mailing Address - Phone:843-756-4021
Mailing Address - Fax:832-756-9124
Practice Address - Street 1:4125 MAIN ST
Practice Address - Street 2:
Practice Address - City:LORIS
Practice Address - State:SC
Practice Address - Zip Code:29569-3023
Practice Address - Country:US
Practice Address - Phone:843-756-4021
Practice Address - Fax:843-756-9124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-15
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC50001951333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC615383Medicaid
NC0425371Medicaid
SC4214160OtherNCPDP
SC719515Medicaid
NC0425371Medicaid