Provider Demographics
NPI:1912963745
Name:ELLOREE PHARMACY LLC
Entity Type:Organization
Organization Name:ELLOREE PHARMACY LLC
Other - Org Name:DELTA PHARMACY & MEDICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HOMER
Authorized Official - Middle Name:D
Authorized Official - Last Name:HIGH
Authorized Official - Suffix:JR
Authorized Official - Credentials:RPH
Authorized Official - Phone:843-761-5255
Mailing Address - Street 1:402 EAST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:MONCKS CORNER
Mailing Address - State:SC
Mailing Address - Zip Code:29461
Mailing Address - Country:US
Mailing Address - Phone:843-761-5255
Mailing Address - Fax:843-899-4970
Practice Address - Street 1:2611 CLEVELAND STREET
Practice Address - Street 2:
Practice Address - City:ELLOREE
Practice Address - State:SC
Practice Address - Zip Code:29047
Practice Address - Country:US
Practice Address - Phone:803-897-2131
Practice Address - Fax:803-897-1129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-21
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC500077623336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDME276Medicaid
SC5312030001Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER