Healthcare Provider Details

I. General information

NPI: 1417951252
Provider Name (Legal Business Name): SUP-RX PHARMACY #53
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 PEARL ST
DARLINGTON SC
29532-3814
US

IV. Provider business mailing address

401 PEARL ST
DARLINGTON SC
29532-3814
US

V. Phone/Fax

Practice location:
  • Phone: 843-393-2552
  • Fax: 843-393-9811
Mailing address:
  • Phone: 843-393-2552
  • Fax: 843-393-9811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number50-000803
License Number StateSC

VIII. Authorized Official

Name: RICKY MCLEOD
Title or Position: OWNER
Credential:
Phone: 803-775-1334