Healthcare Provider Details

I. General information

NPI: 1932118411
Provider Name (Legal Business Name): POWDERSVILLE PHARMACY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10701 ANDERSON RD
EASLEY SC
29642-9309
US

IV. Provider business mailing address

10701 ANDERSON RD
EASLEY SC
29642-9309
US

V. Phone/Fax

Practice location:
  • Phone: 864-295-2503
  • Fax: 864-295-2868
Mailing address:
  • Phone: 864-295-2503
  • Fax: 864-295-2868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number1478
License Number StateSC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier714785
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer

VIII. Authorized Official

Name: MR. GARLAND DELMA SENTELL
Title or Position: PHARMACIST/OWNER
Credential: R.PH
Phone: 864-295-2503