Provider Demographics
NPI:1831696251
Name:SOVEREIGN MEDICAL CONSULTING LLC
Entity type:Organization
Organization Name:SOVEREIGN MEDICAL CONSULTING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:EDMOND
Authorized Official - Last Name:GRACE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:864-451-4250
Mailing Address - Street 1:15 VILLA RD, APT #182
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615
Mailing Address - Country:US
Mailing Address - Phone:864-451-4250
Mailing Address - Fax:
Practice Address - Street 1:15 VILLA RD, APT #182
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615
Practice Address - Country:US
Practice Address - Phone:864-451-4250
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-11
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC3080095351835P1200X
SC101491182305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes305S00000XManaged Care OrganizationsPoint of Service
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC101491182OtherSC DEPARTMENT OF REVENUE