Provider Demographics
NPI:1770112849
Name:FOUNTAIN INN RX LLC
Entity type:Organization
Organization Name:FOUNTAIN INN RX LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:CAUSEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-360-4619
Mailing Address - Street 1:112 HOLLAND TRACE CIR
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-5869
Mailing Address - Country:US
Mailing Address - Phone:864-408-9680
Mailing Address - Fax:864-408-9757
Practice Address - Street 1:106 S WESTON ST
Practice Address - Street 2:
Practice Address - City:FOUNTAIN INN
Practice Address - State:SC
Practice Address - Zip Code:29644-1940
Practice Address - Country:US
Practice Address - Phone:864-408-9680
Practice Address - Fax:864-408-9757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-02
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC7Z1080Medicaid