Provider Demographics
NPI:1780958744
Name:DOGWOOD PHARMACY, LLC
Entity type:Organization
Organization Name:DOGWOOD PHARMACY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:ELVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTANEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:800-628-6965
Mailing Address - Street 1:1325 MILLER RD, SUITE K
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-6541
Mailing Address - Country:US
Mailing Address - Phone:866-840-4067
Mailing Address - Fax:866-514-8299
Practice Address - Street 1:1325 MILLER RD, SUITE K
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-6541
Practice Address - Country:US
Practice Address - Phone:866-840-4067
Practice Address - Fax:866-514-8299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-08
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336H0001X
SC139383336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1780953744Medicaid
2134795OtherPK
SC713938Medicaid
GA003124413AMedicaid