MEDICARE: MCLEOD HEALTH CLARENDON LTC PHARMACY

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	3336L0003X	Long Term Care Pharmacy
2	333600000X	Pharmacy	16726	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2163851	OTHER		PK

General Provider Information

NPI Number	:	1659360873
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MCLEOD HEALTH CLARENDON LTC PHARMACY

Provider Business Mailing Address
First Line	:	50 E HOSPITAL ST
Second Line	:	STE 1B
City	:	MANNING
State	:	SC
Zip	:	29102-3149
Country	:	US
Telephone Number	:	803-435-5272
Fax Number	:	803-435-5271

Provider Business Practice Location Address
First Line	:	50 E HOSPITAL ST
Second Line	:	STE 1B
City	:	MANNING
State	:	SC
Zip	:	29102-3149
Country	:	US
Telephone Number	:	803-435-5272
Fax Number	:	803-435-5271

Authorized Official
Title or Position	:	SR VP AND CFO
Name	:	SAMUEL FULTON ERVIN III
Credential	:
Telephone Number	:	843-777-2910

Provider Enumeration Date	:	10/20/2005
Last Update Date	:	02/25/2019

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Directions to “MCLEOD HEALTH CLARENDON LTC PHARMACY ” Practice Location

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