Organization Name: | TIDEWATER PHARMACY & MEDICAL SUPPLY LLC |
NPI Number: | 1053705772 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | CHAD STRAUGHAN (OWNER/PHARMACIST) |
Mailing Address: | 421 Johnnie Dodds Blvd Ste 100 Mount Pleasant |
State: | SC US |
Postal Code: | 29464 |
Phone Number: | 8433756310 |
Fax Number: | 8433756311 |
NPI Enumeration Date: | 03/19/2015 |
NPI Last Update Date: | 01/31/2016 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 3336C0004X |
License Number: | 35780 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | SC |
Taxonomy Type: | Suppliers |
Taxonomy Classification: | Pharmacy |
Taxonomy Specialization: | Compounding Pharmacy |
Taxonomy Definition: | A pharmacy that specializes in the preparation of components into a drug preparation as the result of a Practitioner |