Healthcare Provider Details

I. General information

NPI: 1952471211
Provider Name (Legal Business Name): PALMETTO HEALTH ALLIANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 03/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1308 LAUREL ST
COLUMBIA SC
29201-2514
US

IV. Provider business mailing address

1308 LAUREL ST
COLUMBIA SC
29201-2514
US

V. Phone/Fax

Practice location:
  • Phone: 803-931-8123
  • Fax: 803-931-8201
Mailing address:
  • Phone: 803-931-8123
  • Fax: 803-931-8201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number13821
License Number StateSC

VIII. Authorized Official

Name: DAVID MARSH
Title or Position: LEAD PHARMACIST
Credential:
Phone: 803-931-8124