Healthcare Provider Details

I. General information

NPI: 1790210839
Provider Name (Legal Business Name): MUKTA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2017
Last Update Date: 03/10/2022
Certification Date: 03/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 N MAIN ST STE E
FOUNTAIN INN SC
29644-1336
US

IV. Provider business mailing address

400 ABBY CIR
GREENVILLE SC
29607-6429
US

V. Phone/Fax

Practice location:
  • Phone: 864-210-1811
  • Fax: 864-210-1810
Mailing address:
  • Phone: 864-991-7972
  • Fax: 864-210-1810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number17200
License Number StateSC

VIII. Authorized Official

Name: ASHISH B PATEL
Title or Position: PIC
Credential: RPH
Phone: 864-210-1811