Provider Demographics
NPI:1770888935
Name:GOOD VITAL CARE, LLC
Entity type:Organization
Organization Name:GOOD VITAL CARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACISTS
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:J
Authorized Official - Last Name:HYATT-SWEAT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-327-2092
Mailing Address - Street 1:1243-B EBENEZER ROAD
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-4715
Mailing Address - Country:US
Mailing Address - Phone:803-327-2092
Mailing Address - Fax:803-327-2093
Practice Address - Street 1:1243-B EBENEZER ROAD
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-4715
Practice Address - Country:US
Practice Address - Phone:803-327-2092
Practice Address - Fax:803-327-2093
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GOOD PHARMACY OF ROCK HILL, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-01-20
Last Update Date:2011-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11331251F00000X, 332BP3500X, 333600000X, 3336H0001X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No251F00000XAgenciesHome Infusion
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No333600000XSuppliersPharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC711331OtherMEDICAID HIT
SCDE3361OtherMEDICAID DME
SC711331OtherMEDICAID HIT