MEDICARE: BLACK RIVER GROCERY 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	3336C0003X	Community/Retail Pharmacy	14725	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2141517	OTHER		PK

General Provider Information

NPI Number	:	1689730913
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLACK RIVER GROCERY LLC

Provider Business Mailing Address
First Line	:	15 W ASHLAND ST
Second Line	:
City	:	ANDREWS
State	:	SC
Zip	:	29510-2543
Country	:	US
Telephone Number	:	843-264-3291
Fax Number	:	843-264-5425

Provider Business Practice Location Address
First Line	:	15 W ASHLAND ST
Second Line	:
City	:	ANDREWS
State	:	SC
Zip	:	29510-2543
Country	:	US
Telephone Number	:	843-264-3291
Fax Number	:	843-264-5425

Authorized Official
Title or Position	:	PIC
Name	:	TROY BLAKELY LAMB
Credential	:	PHARMD
Telephone Number	:	843-264-3291

Provider Enumeration Date	:	12/29/2006
Last Update Date	:	10/31/2025

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Directions to “BLACK RIVER GROCERY LLC ” Practice Location

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