Healthcare Provider Details

I. General information

NPI: 1912963745
Provider Name (Legal Business Name): ELLOREE PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2611 CLEVELAND STREET
ELLOREE SC
29047
US

IV. Provider business mailing address

402 EAST MAIN STREET
MONCKS CORNER SC
29461
US

V. Phone/Fax

Practice location:
  • Phone: 803-897-2131
  • Fax: 803-897-1129
Mailing address:
  • Phone: 843-761-5255
  • Fax: 843-899-4970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number50007762
License Number StateSC

VIII. Authorized Official

Name: VAN WILLIS HIGH II
Title or Position: OWNER
Credential:
Phone: 843-761-5255