Healthcare Provider Details

I. General information

NPI: 1831696251
Provider Name (Legal Business Name): SOVEREIGN MEDICAL CONSULTING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2018
Last Update Date: 04/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 VILLA RD, APT #182
GREENVILLE SC
29615
US

IV. Provider business mailing address

15 VILLA RD, APT #182
GREENVILLE SC
29615
US

V. Phone/Fax

Practice location:
  • Phone: 864-451-4250
  • Fax:
Mailing address:
  • Phone: 864-451-4250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number308009535
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number101491182
License Number StateSC

VIII. Authorized Official

Name: DR. EDWARD EDMOND GRACE
Title or Position: PRESIDENT
Credential: PHARM.D.
Phone: 864-451-4250