Provider Demographics
NPI:1881606093
Name:CORAM HEALTHCARE CORPORATION OF SOUTH CAROLINA
Entity type:Organization
Organization Name:CORAM HEALTHCARE CORPORATION OF SOUTH CAROLINA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR VP
Authorized Official - Prefix:
Authorized Official - First Name:VITO
Authorized Official - Middle Name:
Authorized Official - Last Name:PONZIO
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:303-672-8631
Mailing Address - Street 1:1675 BROADWAY
Mailing Address - Street 2:SUITE 900
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80202-4675
Mailing Address - Country:US
Mailing Address - Phone:303-672-8631
Mailing Address - Fax:303-298-0047
Practice Address - Street 1:1941 SAVAGE RD
Practice Address - Street 2:SUITE 500AA
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-4704
Practice Address - Country:US
Practice Address - Phone:843-769-5544
Practice Address - Fax:843-769-4300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X, 251F00000X, 261QI0500X
SC50-003160332BP3500X, 333600000X, 3336C0003X, 3336H0001X, 3336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered251E00000XAgenciesHome Health
Not Answered251F00000XAgenciesHome Infusion
Not Answered261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
Not Answered332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Not Answered3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Not Answered3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4219350OtherNCPDP
SCDME151Medicaid
SC731608Medicaid
SC50-003160OtherRX LICENSE
SC50-003160OtherRX LICENSE
SCDME151Medicaid