Provider Demographics
NPI:1770588097
Name:IVA DRUG STORE, INC.
Entity type:Organization
Organization Name:IVA DRUG STORE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:P
Authorized Official - Last Name:BOLES
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:864-348-6138
Mailing Address - Street 1:720 EAST FRONT STREET
Mailing Address - Street 2:P.O. BOX 26
Mailing Address - City:IVA
Mailing Address - State:SC
Mailing Address - Zip Code:29655
Mailing Address - Country:US
Mailing Address - Phone:864-348-6138
Mailing Address - Fax:864-348-2220
Practice Address - Street 1:720 E FRONT ST
Practice Address - Street 2:
Practice Address - City:IVA
Practice Address - State:SC
Practice Address - Zip Code:29655-9089
Practice Address - Country:US
Practice Address - Phone:864-348-6138
Practice Address - Fax:864-348-2220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-14
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC50008094332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC741128Medicaid
SC741128Medicaid