MEDICARE: PAWLEYS ISLAND COMPOUNDING PHARMACY 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	3336C0004X	Compounding Pharmacy	14285	SC

General Provider Information

NPI Number	:	1437495223
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAWLEYS ISLAND COMPOUNDING PHARMACY LLC

Provider Business Mailing Address
First Line	:	9710 OCEAN HWY UNIT 2
Second Line	:
City	:	PAWLEYS ISLAND
State	:	SC
Zip	:	29585-7585
Country	:	US
Telephone Number	:	843-235-0580
Fax Number	:

Provider Business Practice Location Address
First Line	:	9710 OCEAN HWY UNIT 2
Second Line	:
City	:	PAWLEYS ISLAND
State	:	SC
Zip	:	29585-7585
Country	:	US
Telephone Number	:	843-235-0580
Fax Number	:

Authorized Official
Title or Position	:	PHARMACIST IN CHARGE
Name	:	MR. LEWIS WALDREP
Credential	:	RPH
Telephone Number	:	843-235-0580

Provider Enumeration Date	:	12/24/2012
Last Update Date	:	12/24/2012

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