MEDICARE: MODIFICARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy
3	3336C0003X	Community/Retail Pharmacy	6496	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2092185	OTHER	PK
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154365468
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODIFICARE LLC

Provider Business Mailing Address
First Line	:	1023A W DEKALB ST
Second Line	:
City	:	CAMDEN
State	:	SC
Zip	:	29020-4162
Country	:	US
Telephone Number	:	803-424-0064
Fax Number	:	803-425-8173

Provider Business Practice Location Address
First Line	:	1023A W DEKALB ST
Second Line	:
City	:	CAMDEN
State	:	SC
Zip	:	29020-4162
Country	:	US
Telephone Number	:	803-424-0064
Fax Number	:	803-425-8173

Authorized Official
Title or Position	:	OWNER
Name	:	DENO SEBASTIAN
Credential	:
Telephone Number	:	757-763-8588

Provider Enumeration Date	:	06/16/2006
Last Update Date	:	06/09/2023

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Directions to “MODIFICARE LLC ” Practice Location

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