Healthcare Provider Details

I. General information

NPI: 1316135999
Provider Name (Legal Business Name): SELF REGIONAL HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2007
Last Update Date: 12/14/2021
Certification Date: 12/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 SPRING ST
GREENWOOD SC
29646-3860
US

IV. Provider business mailing address

1325 SPRING ST OUT PATIENT PHARMACY
GREENWOOD SC
29646-3860
US

V. Phone/Fax

Practice location:
  • Phone: 864-725-2768
  • Fax: 864-725-5768
Mailing address:
  • Phone: 864-725-4178
  • Fax: 864-725-4102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number15929
License Number StateSC

VIII. Authorized Official

Name: DR. MATTHEW T LOGAN
Title or Position: PRESIDENT AND CEO
Credential: MD
Phone: 864-725-4253