Healthcare Provider Details

I. General information

NPI: 1669742144
Provider Name (Legal Business Name): CHARLESTON ENT ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2011
Last Update Date: 04/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2295 HENRY TECKLENBURG DR
CHARLESTON SC
29414-7801
US

IV. Provider business mailing address

2295 HENRY TECKLENBURG DR
CHARLESTON SC
29414-7801
US

V. Phone/Fax

Practice location:
  • Phone: 843-793-6402
  • Fax: 866-227-6107
Mailing address:
  • Phone: 843-793-6402
  • Fax: 866-227-6107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number13762
License Number StateSC

VIII. Authorized Official

Name: JAMES VECCHIOLLA
Title or Position: DIRECTOR OF PHARMACY
Credential:
Phone: 843-793-6402